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,.4 



PHYSICAL EXPLORATION 



DIAGNOSIS OF DISEASES 



AFFECTING THE 



RESPIRATORY ORGANS 



BY 



AUSTIN FLINT, M.D., 

PROFESSOR OF THE THEORY AND PRACTICE OP MEDICINE IN THE UNIVERSITY OF LOUISVILLE; 

HONORARY MEMBER OF THE MEDICAL SOCIETY OF VIPGINLA, AND OF 

THE KENTUCKY STATE MEDICAL SOCIETY. 





PHILADELPHIA: 

BLANCHARD AND LEA. 

1856. 






Entered, according to Act of Congress, in the year 1856, 

BY BLANCHARD AND LEA, 

In the Clerk's Office of the District Court for the Eastern District of Pennsylvanir 



-V 



C. SHERMAN & SOIs, PRINTERS, 

19 St. James Street. 



TO 



JAMES P. WHITE, FRANK H. HAMILTON, 

GEORGE HADLEY, BENJAMIN R. PALMER, JOHN C. DALTON, JR., 

AND EDWARD M. MOORE, 

WITH WHOM THE AUTHOR WAS FORMERLY ASSOCIATED 
IN THE 

AND 

TO HIS MEDICAL FRIENDS IN THE CITY OP BUFFALO, 

THIS YOLUME 

IS RESPECTFULLY DEDICATED. 



PREFACE. 



The great importance of physical exploration in cases of 
thoracic disease is now generally admitted. "While its scope 
of application, the significance of certain of its phenomena, and 
more especially the mode of their production, furnish occasions 
for discussion and differences of opinion, few intelligent phy- 
sicians, at the present day, refuse to acknowledge that the dis- 
covery of Laennec forms a memorahle epoch in the history of 
medicine ; nor will the claims of this branch of our art on the 
attention of the medical practitioner be denied by any who are 
qualified to place a proper estimate upon its value. But 
although these positions are indisputable, the number who 
give much attention to the principles and practice of physical 
exploration is quite small, its advantages being practically 
rejected by a large proportion of the medical profession. May 
not this be in a measure due to the paucity of works treating 
of the subject specially, and with a degree of fulness commen- 
surate with its importance ? This inquiry, mainly, has led to 
the preparation of this volume. The founder of auscultation 
succeeded in bringing the diagnosis of diseases affecting the 
pulmonary organs to an astonishing degree of precision. Yet 
the labors of those who have followed in the footsteps of their 
illustrious master, have done much for the improvement and 
extension of physical exploration ; so that the great work of 
Laennec, remaining as it ever will a splendid monument of his 
genius and industry, is no longer adequate to a complete expo- 
sition of our existing knowledge. The few special treatises 
which have more recently appeared, are mostly designed as 
manuals for the medical student. The most comprehensive 



VI PREFACE. 

work published in our language witMn late years is tbe admi- 
rable treatise by Prof. Walsbe. In this work, which includes 
diseases of the heart and aorta, embracing also the morbid 
anatomy and treatment, as well as the diagnosis, the conside- 
ration of physical signs is necessarily condensed. My aim has 
been to supply what appears to me a desideratum, viz., a work 
limited to diseases affecting the respiratory organs, treating in 
extenso, and almost exclusively, of the principles and practice of 
physical exploration as applied to the diagnosis of these affec- 
tions. So much, briefly, for the motives and objects which have 
prompted the undertaking. 

In preparing the volume now submitted to the profession, 
my plan has been to treat of the physical signs as regards their 
individual and differential characters, their significance and 
diagnostic relations, separately and combined, without impos- 
ing on myself restraint on the score of brevity. "Whilst I have 
desired not to be either tediously minute or diffuse, I have 
intentionally amplified, somewhat after the usual m.ode of 
oral teaching, under the belief that this course would best 
subserve the interests of the reader, and that the importance of 
the subject renders no apology necessary for the size of the 
book. 

I have striven to make the work as practical as possible ; 
and, therefore, the various topics are considered with almost 
exclusive reference to their direct clinical bearings. Very little 
attention is devoted to theoretical questions. To the mechan- 
ism of physical phenomena relatively small space is accorded, 
recognizing as the only safe basis of our knowledge of their 
significance and pathological relations, clinical facts taken in 
connection with morbid anatomy, and believing that a priori 
deductions from the laws of physics, or analogical inferences 
from experiments made out of the body, and even with the 
dead subject, are to be received with great circumspection. 
The recapitulation in different pathological connections of the 
distinctive characters of the different signs, which, as the 
reader will notice, is a feature of the work, has not arisen from 
inadvertency ; for, whereas, perfect familiarity with these cha- 
racters is indispensable to skill or success in the practice of 
exploration, they are to be fixed in the memory by means of 
repetition, on the principle which underlies the oral system of 



PREFACE. Vll 

acquiring a foreign tongue. The motto, " repetition sans cesse^'' 
adopted by an author of French exercises constructed after this 
system/ is well suited for the student or practitioner who is 
ambitious to excel in physical exploration. 

Whoever undertakes to write a didactic treatise, in effect, 
assumes that he is competent to the task. It is not, therefore, 
unbecoming for me to state that during several years devoted 
to clinical pursuits, the physical exploration of the chest has 
occupied a considerable share of my attention. Of most of 
the practical points embraced in this work, I am able to speak 
from experience. With respect to certain signs, the views 
which I have been led to form from personal observation are 
original. I may particularize here, the characters of pitch dis- 
tinguishing the respiratory sound commonly called rude or 
rough, and which give to a prolonged expiration its signifi- 
cance as a sign of increased density of lung from tuberculous 
or other solid deposit ; also, the relative pitch of the inspira- 
tory and expiratory sounds in the cavernous, as contrasted with 
the bronchial, respiration. Other points, not dwelt upon by 
writers on this subject, which I may mention in this place, are 
the importance of determining the line of the interlobar fis- 
sure, as a means of distinguishing between the percussion-dul- 
ness of lobar pneumonitis and liquid effusion, and the clinical 
value of the souffle or bellows' sound, accompanying the act of 
whispering, as a sign of solidification. In the perusal of the 
work, the reader will perceive that occasionally the results of 
my own observation do not altogether accord with the opinions 
of others. Under these circumstances, I do not hesitate to 
follow a rule which, as it seems to me, in matters purely of 
observation, should not lead to the imputation either of egotism 
or presumption, viz., not to be more ready to distrust one's 
own accuracy than that of others. Were an opposite course 
to be required, there would be small encouragement for 
original research. While engaged in WTiting the work, I have 
been forcibly impressed with the need of farther analytical 
investigation of carefully recorded data. Questions have so 
frequently arisen which are to be settled only by an appeal to 
the results of observation, that I have sometimes been tempted 
to lay aside the pen, and have resumed it only under the con- 

1 Manesca. 



VUl PftFf ACBL 

viclion that sach qnestions mnst^ for a long period, contmue 
to arise ; and that to wait for Uie means of meeting promptly 
every inquiry, is equivalent to an indefinite postponement- 
This field of research, like every other in the extensive domain 
of liledieal science, offers scope for unlimited improvement; and 
it is to be expected that continued efforts in its cultivation will 
develope additional resources^ rendering it more and more 
valuable. 

Endeavoring, as £ir as practicable, to exhibit the actual state 
of our present knowledge of the physical diagnosis of diseases 
of the respiratoiy organs, I have availed m^yself of the latest 
and most approved works on the subject. My acknowledg- 
ments are especially due to the Practical Treatise on the Diseases 
of the Lungs, Heart,* and Aorta, by Professor Walshe, and to 
the Traits Pratique d'Auscultation, etc., by MM. Barth and 
Koger.^ I have also consulted with advantage, the wori^ of 
Stokes, Foumet, Gerhard, C. J. B. Williams, Hughes, Bow- 
ditcb, Swett, Alfred Stille, Holmes, J. Hughes Bennett, and 
Skoda. In addition, numerous papers on particular topics have 
been examined, as well as books treating incidentally of matters 
pertaining to physical exploration, which are referred to in the 
body of the work. 

One of the authors just named has enuncifi-ei views, which, 
fi»m their novelty and boldness, have attracted considerable 
attention. I refer to Professor Skoda, of Yienna. The theory of 
consonance, by which this author attempts to explain some of 
the most important of the physical signs, and upon which he 
bases certain practical conclusions, appears to me very fer from 
being satisfiictorily established. In his clasafication and desig- 
nation of physical signs, I am unable to perceive that aught is 
gained in clearness or simplicity. Some of his assertions per- 
taining to matters of simple observation, involve a denial of 
the positive results of the experience not of one, but of nearly 
all observers — ^for example, that the crepitant rale, as described 
by liaennec, is rarely heard in pneumonitis, and that the per- 
cussion-resonance is not affected by the presence of isolated 
tubercles in a very considerable quantity, unless accompanied 
by an altered condition of the interstitial tissue. Moreover, the 
pervading tone of ihe work tends to create in the mind of the 

' The editioDs c^bodi diese worts fiw 1834. are referred la 



PREFACE. IX 

student a scepticism witli respect to the value of physical 
exploration, which is at variance with the confidence of other 
observers not less experienced than himself. In venturing upon 
these critical remarks, I am alone actuated by a desire that the 
importance of the subj ect should not be undervalued. Frequent 
occasions for reference to the valuable contributions of Pro- 
fessor Skoda will appear in the following pages. 

In order that physical exploration shall be available in the 
hands of practitioners who have neither time nor inclination 
to devote to it special attention, to the prejudice of attainments 
in other branches of medical knowledge, as much simplicity 
in its principles and practice as comports with a due regard to 
its usefulness, is to be desired. ITeedless distinctions and over 
refinements are to be deprecated. Mutations in classification 
and nomenclature are as much as possible to be avoided. With 
these views, I have refrained from suggesting additions or 
changes, which, should they even be considered improvements, 
might occasion complexity and confusion ; and I have passed 
over some points which, from their dubious or unimportant 
character, seemed likely to prOve a source of embarrassment, 
rather than an advantage to the student. The only innova- 
tions I have ventured to propose are the substitution of a new 
name for rude or rough respiration, viz., broncho-vesicidar, and 
the use of the terms vesiculo-tympanitic resonance, applied to a 
percussion-sound combining the tympanitic and vesicular quali- 
ties, and broncho-cavernous respiration, denoting a mixture of 
the cavernous and bronchial modifications of the respiratory 
sound. 

In conclusion, I embrace this opportunity to express acknow- 
ledgments to my friend. Professor Alfred Stills, for kindly con- 
senting to read the proofs of the work as it has passed through 
the press. While I have no right to hold him responsible for 
any of its defects, I am truly grateful to him for many valuable 
suggestions. 

University of Louisville, Ky. 
February, 1856. 



CONTENTS, 



ii^troductio:n\ 

SECTION I. 

Preliminary Points pertaining to the Anatomy and Physiology of 

THE Respiratory Apparatus, . . . . .17 

1. Thoracic Parietes, . . . . . . 17 

2. Pulmonary Organs, . . . . . .34 

3. Trachea, Bronchi, and Larynx, .... 46 

a. Trachea, ....... 46 

b. Bronchi, ....... 47 

c. Larynx, ....... 49 

SECTION II. 

Topographical Divisions of the Chest, .... 54 

1. Anterior Regions, . . . . . . .56 

2. Posterior Regions, ...... 60 

3. Lateral Regions, . . . . . . .61 



PART I. 
Physical Exploration of the Chest, ... 65 

CHAPTER I. 

Definitions — Different Methods of Exploration — General Remarks, 6o 

CHAPTER 11. 

Percussion, ........ 75 

I. Percussion in Health, ...... 78 

a. Post-Clavicular Region, . . . . .80 

b. Clavicular Region, . . . . . 81 

c. Infra-Clavicular Region, . . . . .81 

d. Scapular Region, ...... 83 



Xll 



CONTENTS. 



e. Inter-Scapular Region, 

f. Mammary Region, 

g. Infra-Mammary Region, . . 
h. Sternal Region, 

i. Infra-Scapular Region, 
k. Lateral Regions, 
II. Percussion in Disease, . 

a. Exaggerated Vesicular Resonance, 

b. Diminished Resonance or Dulness, 

c. Absence of Resonance or Flatness, 

d. Tympanitic Resonance, 

III. Summary, .... 

IV. History, . . . 



84 

84 

87 

89 

91 

92 

98 

100 

102 

108 

111 

122 

124 



CHAPTER III. 

Auscultation, ....... 

I. Auscultation in Health, ..... 

a. Phenomena incident to Respiration, . 

1. Tracheal Respiration, .... 

2. Bronchial Respiration, .... 

3. Vesicular Respiration, .... 

b. Phenomena incident to the Voice, 

1. Tracheal Voice, ..... 

2. Bronchial Voice, ..... 

3. Normal Vesicular Vocal Resonance, 

c. Brief Summary of Facts, .... 

d. Phenomena incident to the act of Coughing, 
II. Auscultation in Disease, ..... 

a. Phenomena incident to Respiration, 

1. Modified Respiratory Sounds, 

a. Increased Intensity of the Vesicular Murmur — 

Exaggerated Respiration, . 

b. Diminished Intensity of the Vesicular Murmur — 

Feeble or Weak Respiration, 
Suppressed Respiration, ' . 
Bronchial Respiration, 
Broncho-Vesicular or Rude Respiration, 
Cavernous Respiration, 

Tabular View of the Distinctive Characters per- 
taining to the Different Abnormal Modifications 
in Quality, Pitch, etc., of Respiratory Sounds, 
h. Shortened Inspiration, 

i. Prolonged Expiration, .... 
k. Interrupted Respiration, 

2. Adventitious Respiratory Sounds or Rales, . 

a. Table showing the Number, Names, and Anatom 
cal Situations of the Pulmonary Rales, 

b. Sibilant Rale, .... 



126 
136 
137 
137 
140 
146 
163 
164 
167 
168 
173 
174 
175 
175 
176 

177 

180 
185 
187 
197 
202 



209 
210 
211 
214 
216 

219 
220 



CONTENTS. 



Xlll 



c. Sonorous Rale, .... 

d. Mucous Rales, .... 

e. Sub-crepitant Rale, .... 

f. Crepitant Rale, .... 

g. Cavernous Rale or Gurgling, 
h. Indeterminate Rales, 
i. Table Exhibiting tlie Distinctive Characters and 

Diagnostic Indications of the Different Rales, 
j. Attrition or Pleural Friction Sounds, 

b. Phenomena Incident to the Voice, 

1. Exaggerated Vocal Resonance and Bronchophony, 

2. Diminished and Suppressed Vocal Resonance, 

3. Cavernous and Amphoric Voice, Pectoriloquy, . 

4. iEgophony, ..... 

5. Summary of Facts pertaining to Vocal Signs. 

c. Phenomena incident to the Act of Coughing, 

1. Bronchial Cough, .... 

2. Cavernous Cough, .... 

d. Metallic Tinkling, ..... 

e. Abnormal Transmission of the Sounds of the Heart, 
History, ...... 

CHAPTER IV. 

Inspection, . . 

1. Morbid Appearances pertaining to Size and Form of the Chest, 

2. Morbid Appearances pertaining to the Respiratory Movements, 

3. Summary, ....... 

4. History, ....... 

CHAPTER V. 

Mensuration, ....... 

1. Mensuration with reference to Abnormal Alterations in Size, . 

2. Mensuration with reference to the Abnormal Alterations in the 

Extent of Respiratory Movements, 

3. Summary, ...... 

4. History, ....... 



Palpation, . 
Summary,. 
History, 



StJCCUSSION, 

Summary, . 

History, 



CHAPTER VI. 



CHAPTER VII. 



221 
223 
226 
229 
235 
237 

240 
242 
249 
251 
261 
263 
267 
275 
279 
279 
280 
282 
289 
292 



295 
297 
304 
308 
311 



312 
312 

317 
320 
322 



323 
329 
329 



330 
332 
332 



XIV 



CONTEXTS. 



CHAPTER Vni. 

ReCAPITULATOET ExUMERATIOy OF THE PHYSICAL SlGXS FURNISHED BY 

THE Several Methods of Exploratiox, .... 333 



CHAPTER LK. 

CORRELATIOX OF PHYSICAL SiGXS, .... 

1. Signs Correlative to those furnislied by Percussion, 

2. Signs Correlative to those furnished by Auscultation, 



336 
338 
342 



PAET 11. 

Diagnosis of Diseases Affegtixg the Respiratory Organs, 351 



CHAPTER I. 

Broxchitis, Pulmoxary or Broxchial Catarrh, 

1. Acute Bronchitis, 

a. Physical Signs, 

b. Diagnosis, 

c. Summary of Physical Signs belonging to Acute Ordinary 
Bronchitis, .... 

2. Capillary Bronchitis, 

a. Physical Signs and Diagnosis, 

b. Summary of Physical Signs, . 

3. Pseudo-Membranous or Plastic Bronchitis, 

a. Physical Signs and Diagnosis, 

b. Summary of Physical Signs, 

4. Chronic Bronchitis, . 

a. Physical Signs, 

b. Diagnosis, 

c. Summary of Physical Signs, 

5. Secondary Bronchitis, 

6. Bronchial or Pulmonary Catarrh, 

CHAPTER n. 

DlLATATIOX AXD COXTRACTIOX OF THE BrOXCHIAL TuBES — PeRTUSSIS 

AsTHilA, ........ 

1. Dilatation of the Bronchial Tubes, .... 

a. Physical Signs, ...... 

b. Diagnosis, ....... 

c. Summary of the more important of the Diagnostic Cha- 
racters, ....... 

2. Contraction of the Bronchial Tubes, .... 



352 
353 
353 
357 

362 
.362 
362 
369 
369 
371 
372 
373 
373 
375 
377 
377 
378 



380 
380 
383 
385 

391 
391 



CONTENTS. 



XV 



3. Pertussis — Hooping Cough, .... 

Physical Signs and Diagnosis, 

4. Asthma, ....... 

a. Physical Signs, ..... 

b. Diagnosis, ...... 

c. Summary of Physical Signs, 

CHAPTER III. 

Pneumonitis — Imperfect Expansion (Atelectasis) and Collapse, 

1. Acute Lobar Pneumonitis, .... 

a. Physical Signs, ..... 

b. Diagnosis, ...... 

c. Summary of Physical Signs, .... 

2. Lobular Pneumonitis, ..... 

a. Physical Signs and Diagnosis, 
.3. Chronic Pneumonitis, ..... 



395 
395 
397 
397 
398 
400 



401 
401 
404 
421 
431 
432 
435 
440 



CHAPTER ly. 



Emphysema, 



1. Vesicular Emphysema, 

a. Physical Signs, 

b. Diagnosis, 

c. Summary of Physical Signs, 

2. Interlobular Emphysema, 



443 
443 
444 
452 
455 
455 



CHAPTER y. 

Pulmonary Tuberculosis — Bronchial Phthisis, . . . 458 

a. Physical Signs, . . . . . . 461 

b. Diagnosis, ........ 488 

c. Summary of Physical Signs, ..... 502 

Acute Phthisis, . . . . . . .503 

Retrospective Diagnosis of Tuberculosis, . . . 506 

Tuberculosis of the Bronchial Glands — Bronchial Phthisis, . 509 





CHAPTE 


R yi. 




MO 


NARY OEdema — Gangrene of the 


Lungs — Pulmonary Apoplexy 






— Cancer of the Lungs — Cancer in the Mediastinum, 


512 


L 


Pulmonary OEdema, 




512 




a. Physical Signs, 


. 


513 




b. Diagnosis, . 




514 




c. Summary of Physical Signs, 




515 


2. 


Gangrene of the Lungs, 




515 




a. Physical Signs, 




516 




b. Diagnosis, 




518 




c. Summary of Physical Signs, 




520 


3. 


Pulmonary Apoplexy, . 




521 



XVI 



CONTENTS. 



a. Physical Signs, 

b. Diagnosis, 

c. Summary of Physical Signs, 

4. Cancer of the Lungs, . 

a. Physical Signs, 

b. Diagnosis, 

c. Summary of Physical Signs, 

5. Cancer in the Mediastinum, 

a. Physical Signs, 

b. Diagnosis, 

CHAPTER YII. 

Acute Pletjritis — Chroxic Pleuritis — Empyema — Htdrothorax— 
Pneumothorax — Pxeumo-Hydrothorax — Pleuralgia — Dia 
phragmatic Herxia, 

1. Acute Pleuritis, 

a. Physical Signs, 

b. Diagnosis, 

c. Summary of Physical Signs, 

2. Chronic Pleuritis, 

a. Physical Signs, 

b. Diagnosis, 

c. Retrospective Diagnosis, 

d. Summary of Physical Signs, 

3. Empyema, . 

4. Hydrothorax, 

5. Pneumothorax, 

6. Pneumo-Hydrothorax. . 

a. Physical Signs, 

b. Diagnosis, 
0. Summary of Physical Signs, 

7. Pleuralgia, 

8. Diaphragmatic Hernia, 

a. Physical Signs, 

b. Diagnosis, 

CHAPTER VIII. 

Diseases Affectixg the Trachea axd Lartxx — Foreigx Bodies ix 
THE Air-Passages, 

1. Auscultation of the Trachea and Larynx, 

2. Examination of the Chest, 

3. Foreign Bodies in the Air-Passages, 

a. Summary of Physical Signs, . 

APPENDIX. 

Ox THE Pitch of the Whisperixg Souffle oyer Pulmoxary Exca 

YATIOXS, ....... 



PHYSICAL EXPLOEATION. 



INTRODUCTION. 
SECTION I. 

PRELIMINARY POINTS PERTAINING TO THE ANATOMY AND 
PHYSIOLOGY OF THE RESPIRATORY APPARATUS. 

The study of diseases affecting the respiratory apparatus involves, 
as a point of departure, acquaintance with the several structures, 
organs, and functions which this apparatus embraces. To this pre- 
paratory knowledge it is presumed, of course, the reader has already 
given more or less attention ; but it will be useful to review certain 
points pertaining to the anatomy and physiology of this portion of 
the organism, which will be found to have direct and intimate patho- 
logical relations. To these points this section will be mainly limited, 
omitting details other than those of special importance in their bear- 
ings on the subjects to be subsequently considered. 

The respiratory apparatus comprises 1st, the thoracic parietes, 
inclusive of the diaphragm ; 2d, the pulmonary organs contained 
within the thoracic cavity ; 3d, the canal or tube leading from the 
lungs to the pharynx, consisting of the bronchi and their subdivi- 
sions, the trachea, and larynx. The throat, mouth, and nasal passages, 
although involved in respiration, are rather adjuncts of the respira- 
tory apparatus than constituents of it, their construction having 
more direct reference to other functions. 

I. The Thoracic Parietes. 

The portion of the skeleton called the thorax is composed of the 
dorsal vertebrae, the ribs, and the bones of the sternum, forming by 
their union, together with their intervening cartilages, a truncated 

2 



18 ANATOMY AND PHYSIOLOGY. 

cone, designed to protect the organs which it contains, and to be sub- 
servient to certain movements concerned in respiration. The bony 
arches, the ribs, exclusive of the two last on each side (reckoning, as 
is usual, from the summit of the cone downward), are joined, either 
to the sternum, or to each other, bv cartilages to which the walls of 
the chest are in a great measure indebted for their elasticity and 
mobility. The superior seven ribs joined to the sternum are called 
the true ribs, and the remaining five on each side are distinguished 
as x}iQ false ribs. The two lowest on each side, from the fact that 
their anterior extremities are disconnected from those situated above 
them, as well as from each other, are known as the floating ribs. 
The elasticity of the costal cartilages is greatest in early life : it 
becomes impaii-ed, as a general rule, in proportion to age, and with 
advanced years may be nearly lost in consequence of ossification. 
Under these circumstances the alternate increase and diminution of 
the thoracic capacity with the two acts of respiration, so far as the 
successive expansion and contraction of the thoracic walls are therein 
involved, must of necessity be in some measure restrained. 

The dii'ection of the first rib is nearly horizontal. The remainder 
have an oblique direction downward, the obliquity increasing with 
each inferior rib. Below the third rib the costal cartilages also have 
an oblique direction, but not corresponding to that of the ribs. 
From the point of theii' attachment to the ends of the ribs, they 
pursue an upward direction to their sternal connections. Hence a 
line coincident with the axis of these ribs, forms with a line passing 
through the axis of their cartilages, an angle which is more acute 
with each inferior rib. The length of the costal cartilages also in- 
creases successively with the three lowest of the true ribs. These 
anatomical points, viz., the oblique downward direction of the ribs, 
and the oblique upward direction of their cartilaginous prolongations, 
are provisions for the respu'atory movements, so far as these move- 
ments relate to the anterior and lateral portions of the chest. With 
the act of inspiration, more especially when its force is voluntarily 
augmented, the lateral and antero-posterior diameters are increased. 
This is effected chiefly by the elevation of the ribs, by which their 
obliquity is diminished, causing them to approximate and even attain 
to a horizontal direction, tending thus to bring the ribs and the costal 
cartilages on a continuous line, diminishing or abohshing the acute 
angle formed by the union of the ribs and cartilages. After the 
cessation of the motive power which effects these changes, in other 



THE THORACIC PARIETES. 19 

words, with the act of expiratioiij the elasticity of the cartilages suf- 
fices to restore that relation to the ribs which is natiirally assumed. 
These movements are abnormally increased and diminished in conse- 
quence of different forms of disease. A change, also, as regards the 
oblique direction of the ribs is attendant on certain thoracic affections, 
viz., pleurisy with a large accumulation of liquid in the pleural sac ; 
the presence of liquid and gas in pneumo-hydrothorax, and in some 
instances of abnormally distended lung, constituting a form of 
emphysema. In connection with these affections the same changes 
are mechanically produced which are effected by a forcible act of in- 
spiration, with the important difference, that while the enlargement 
of the chest in the latter case is but for an instant, in the former 
case it persists so long as the morbid conditions which have induced 
it continue. 

The margins of the- ribs are not in contact, but separated, leaving 
what are termed the intercostal spaces. In consequence of the pro- 
gressively increasing obliquity in the direction of the ribs the inter- 
costal spaces are broader in front than behind. Under different 
morbid conditions these spaces are increased and diminished in 
width. The former is incident to the accumulation of a large quan- 
tity of liquid in the chest, the latter to contraction of the chest 
following the removal of this liquid by absorption or otherwise. In 
the female skeleton the upper ribs are more widely separated than 
in the male, and they possess also, relatively, a greater degree of 
mobility. This anatomical difference in the two sexes has relation 
to the greater part which the summit of the chest takes in the 
respiratory movements in the female. 

The intercostal spaces when the thorax is invested with the soft 
parts, are filled with muscular substance, which constitute a portion 
of the active agents employed in carrying on the respiratory move- 
ments. These intervening muscular layers are depressed below the 
level of the ribs, causing furrows, which are called the intercostal de- 
pressions. In persons with small or moderate adipose deposit, these 
depressions are plainly indicated on the surface, being observable 
especially in front and laterally, at the lower part of the chest. 
They are everywhere visible, except in the portions covered by the 
scapula, in cases of great emaciation. A change as respects this 
anatomical point occurs in certain diseases, viz., when there is an 
accumulation of a large quantity of liquid ; and sometimes when the 
chest is dilated by over-distended lung in emphysema. Under these 



20 ANATOMY AX D PHYSIOLOGY. 

circumstances, especially with the former condition, the intercostal 
depressions are abolished, and the interrening integument may even 
project beyond the level of the ribs when a very large quantity of 
liquid is contained in the pleural sac. 

The scapula and clavicle, with the soft parts, give to the thorax a 
shape quite different from that which it presents divested of these 
appendages. Compared to a truncated cone, the base is now above. 
These superadded bones, certain muscles investing portions of the 
thoracic walls, and, in the female, the mammary gland, offer obstacles 
in the way of exploring the chest for the physical signs of disease 
which will be noticed hereafter in connection with the consideration 
of these signs. 

The partition wall separating the chest from the abdomen is the 
tendino-musctJar septum, the diaphragm, springing from the lumbar 
vertebrae, from the first to the fourth inclusive, and attached to the 
six inferior ribs. Examined from below it forms a vaulted or arched 
roof of the abdominal cavity, its upper surface having a correspond- 
ing convexity extending into the thoracic cavity on each side. The 
height to which this convexity rises in the two sides is not equal, 
being greater in the right than in the left side. In the former it 
rises as high as the fourth intercostal space ; in the latter to a level 
with the fifth rib. Thus the right chest has a vertical diameter 
somewhat less than that of the left. Accumulation of liquid within 
the pleural sac, and dilatation of the lungs in some cases of emphy- 
sema, may cause, mechanically, depression of the diaphragmatic 
arch ; and, on the other hand, enlargement of the liver on the right 
side, and, on the left side, enlargement of the spleen, or distension 
of the stomach, will produce an elevation above the normal height. 

The contraction of the muscular structure entering into the com- 
position of the diaphragm diminishes its vaulted form, depressing it 
to a plane, thereby enlarging the vertical diameter of the thoracic 
space. In this way it becomes the most important agent in the act 
of inspiration, resuming its convexity with the act of expiration. 
These movements are liable to be restrained, or arrested by various 
affections, which will be presently mentioned. 

Considered as divided into lateral halves, the thoracic parietes on 
the two sides, not only as respects the skeleton, but when invested 
with the soft parts, should be nearly symmetrical, so that any con- 
siderable deviations in this point of view, denote either present 
disease, or deformity. An exception relates to the semicircular 



THE THORACIC PAKIETES. 21 

measurement at the middle and inferior portion of the chest. The 
right side usually, but by no means invariably, measures somewhat 
more than the left, the average difference being about half an inch. 
Of 133 cases of persons in good health in which measurements were 
made by M. Woillez, the right semi-circumference exceeded the left 
in 97 ; the left exceeded the right in 9, and both sides were equal 
in 27. The greater size of the right side, as determined by measure- 
ment, is usually attributed to the presence of the liver on that side. 
The facts presented by the author just named, however, seem to show 
that it depends, in a measure at least, on the greater use of the right 
upper extremity, which is habitual with most persons. In no instance 
in which the persons were right-handed did the left exceed the right 
SIDE in measurement; on the other hand, of cases in which the 
persons were left-handed^ in three the left side exceeded the right, 
and in the remaining two cases both sides were equal. In a per- 
fectly symmetrical chest the shoulders should be on the same level ; 
and in the male, the nipples situated on the fourth rib, or the foui'th 
intercostal space, should be on the same transverse line, and equi- 
distant from the centre of the sternum. The general law of sym- 
metry as regards correspondence in similar portions of the chest on 
the two sides, is of importance in determining the existence of intra- 
thoracic diseases ; and, with reference to its application, it is to be 
borne in mind that certain past affections are liable to leave devia- 
tions more or less permanent. The most common cause of deformity 
is spinal curvature, which may be sufficient to disturb the symmetry 
of the two sides without existing to a degree to be noticed unless a 
careful comparison be instituted. Cases of slight lateral curvature 
depressing the shoulder and nipple of one side (oftener the right than 
the left side), approximating the margins of the ribs, and diminishing 
the semi-circumference, are very frequent, and liable, without special 
attention, to be overlooked. Certain diseases within the chest lead 
to marked alterations in the conformation on one side. This is true 
especially, as will be seen hereafter, of chronic pleurisy. The chest 
on one or both sides may be deformed in various ways irrespective of 
spinal curvature. Thus the sternum may project unnaturally, 
causing the ''chicken" or "pigeon breast," or on the contrary more 
or less depressed ; there may be flattening on one side produced per- 
haps by pressure from the arm of the nurse in early infancy ; 
contraction at the lower part of the chest in females, occasioned by 
tight lacing ; distortions from fractures or other injuries, etc. These 



*2-2 A^'ATO^IY A>-D PHYSIOLOGY. 

deviations from sjmmetrj are sufficiently obvious, and will not there- 
fore escape notice. Practically, they are of great importance in 
determining the physical signs oi present disease. The greater portion 
of these signs, as "will be seen hereafter, being based on the assump- 
tion that, irrespective of present disease, the two sides of the chest 
are in unison, it becomes obviously an essential preliminary to deter- 
mine, in individual cases, to what extent the law of symmetry is 
applicable. The researches by M. Woillez^ show that chests 
presenting in all particulars complete regularity of conformation are 
found in only the proportion of about twenty of every hxmdred per- 
sons. Deviations from symmetry, either disconnected from disease 
(physiological), or resulting from previous morbid conditions (patho- 
logical), therefore, exist to a greater or less extent, in a large 
proportion of individuals. This fact would impair very materially the 
value of physical exploration were it not practicable, as it generally 
is, to determine whether deviations which may be discovered are due 
to present disease, or existed previously. 

The respiratory movements involve certain points important to be 
premised in addition to those already noticed. 

A complete respiration, as is well known, comprises two acts, viz., 
an act of inspiration, and an act of expiration. In health, after 
adult age, the respirations are repeated from 14 to 20 times per 
minute, the habitual frequency varying considerably within healthy 
limits in different individuals. The frequency is somewhat greater 
in females than in males, and still greater in children. Deviations 
as regards the frequency of the respirations, exceeding the limits of 
health, are important symptoms of disease. In various affections 
compromising the function of hsematosis, the frequency of the re- 
spirations is considerably increased, rising for example in bronchitis 
affecting the smaller tubes, to 30, 40, 50, 60, or even a still greater 
number, per m in ute. On the other hand, an abnormal diminution in 
frequency accompanies certain morbid conditions of the nervous 
system affecting indirectly the respiration. Thus, the respirations 
are morbidly infrequent, or slow, in apoplexy, and coma, however 
induced. The immediate object of the act of inspiration is the 
enlargement of the thoracic space, the air rushing in to fill the vacuum 

- " Rechercties pratiques sur rinapection et la mensxuation de la poitrine, considerees 
comme moyens diagnostiqaes complementaires de la percussion et de rauscultation." 
Paris. 1837. Archives Generales de 31edecine, Seme Serie, tome i, p. 73. 



THE THORACIC PARIETES. ^ 23 

thus created within the air cells and tubes of the lungs. This 
enlargement is effected by means of muscles attached to the thoracic 
walls, on the one hand, and, on the other hand, by the depression of 
the diaphragm. The immediate object of expiration is to restore the 
chest to the dimensions it naturally assumes when not acted on by 
the dilating muscles, and to contract it sometimes beyond that point, 
thus causing expulsion of the air received by the act of inspiration. 
The simple restoration of the chest is due mainly to the elasticity of 
the dilated parts, but contraction beyond the dimensions which it 
naturally assumes, is eiFected by expiratory muscles. The move- 
ments incident to the two acts, respectively, in ordinary or tranquil 
respiration ; the modifications exhibited when the breathing is exag- 
gerated or forced ; the normal differences to be observed in different 
persons ; the variations due to age, sex, etc., are physiological points, 
not only interesting in themselves, but of utility in order to appre- 
ciate the aberrations associated with diseases of the respiratory 
apparatus. In bestowing some consideration on these points I shall 
not detain the reader with minute descriptions, still less engage in 
discussions relative to the mechanism of respiration, which, however 
much of interest they may possess for one desirous of investigating 
the subject fully, are not of special importance in view of pathological 
relations. 

In ordinary breathing, in the male, the diaphragm is usually the more 
important and indeed sometimes almost the sole efficient agent. The 
diaphragmatic movements are indicated by a perceptible rising and 
falling of the abdomen. But in certain diseases these movements are 
to a greater or less extent restrained, and they may even be com- 
pletely arrested. They are notably diminished in acute peritonitis, 
being unconsciously repressed in consequence of the pain which they 
occasion ; and they are mechanically prevented by a great quantity 
of liquid within the peritoneal sac, by enormous distension of the 
stomach or intestines with gas, and by abdominal tumors, inclusive 
of pregnancy. Under these circumstances the thoracic muscles 
take on a supplementary activity, which are rendered sufficiently 
obvious by the increased movements of the thoracic walls. The 
breathing is then said to be thoraeio or costal. On the other hand, 
the movements of the ribs are voluntarily repressed in consequence 
of the pain incident thereto in acute pleurisy, or in pleurodynia, 
and they are mechanically limited by rigidity and ossification of the 
costal cartilages. The diaphragm, in this case, takes on an increased 



24 ANATOMY AND PHYSIOLOGY. 

action. The breathing is then distinguislied as diapTiragmatic or 
abdominal.^ the latter term denoting the fact that this supplementary 
activity is manifested by a corresponding increase in the visible 
rising and falling of the abdominal walls. The deviations from 
normal respiration known as thoracic or costal, and diapJtragmatic 
or ahdominalj thus not only indicate the existence of disease, but 
point to its situation. 

By certain intra-thoracic affections the movements of the chest are 
diminished, or suspended on one side, and, by way of compensation, 
abnormally increased on the other side. This obtains in cases of 
copious liquid effusion within one of the pleural sacs ; and in some 
instances, of the affection called emphysema when limited to one 
lung. Paralysis of the muscles of a lateral half of the body (hemi- 
plegia) may also be attended by diminished thoracic movements of 
the affected side. 

Analysis of the movements of the thoracic walls developes other 
circumstances which are to be noted. The enlargement of the chest, 
exclusive of the diaphragm, in inspiration, is effected by the action 
of the thoracic muscles elevating the ribs, which, as has been seen, 
pursue an oblique direction, forming an angular connection with 
the costal cartilages. In proportion as the ribs are thus raised, 
the angles just referred to become less acute, and the ribs approach 
to a horizontal direction, the ribs and cartilages together approxi- 
mating to a continuous line. At the same time the sternum is raised 
upward and projected forward. The ribs, also, are rotated back- 
ward at their spinal junction. The result is, the cavity of the chest 
becomes enlarged in every direction. Owing to the greater length 
of the lower true ribs as well as of their cartilages, and the greater 
acnteness of the angle formed by the union of the former with the 
latter, these elevation and expansion movements, in tJie male, are 
much more marked in the lower, than the upper part of the chest ; 
and they are greater during the middle, than either at the beginning 
or the end of the inspiratory act. In ordinary breathing, the ribs 
at the summit of the male chest appear to have little or no part in 
the thoracic movements. x\ccurate measurement shows that they do 
not remain quiescent, but the motion is usually so slight as scarcely 
to be perceived. The movements are mainly confined to the lower 
part of the chest and the abdomen, and frequently appearing to be 
chiefly limited to the latter. This, it is to be borne in mind, is true 
of ordinary breathing in the male sex. In exaggerated or forced 



THE THORACIC PARIETES. 25 

breathing, and in the female, the respiratory movements present 
important modifications. It will facilitate the description of these 
modifications to adopt a subdivision of the thoracic movements m.ade 
by MM. Beau and Maissiat,^ which I am satisfied from my own ob- 
servations is founded in nature. From an examination of a large 
number of individuals these observers resolve normal difi'erences of 
breathing in the two sexes, as denoted by obvious movements, into 
three kinds, or as styled by them, types. In many persons, as already 
stated, ordinary breathing is carried on almost exclusively by the 
diaphragm. In these persons the chief visible evidences of alternate 
enlargement and diminution of the thoracic space, with the two respi- 
ratory acts, consist in the rising and falling of the abdomen. This 
is called the abdominal type of respiration. In other persons, of the 
male sex, movements of the lower part of the chest, from the seventh 
rib, inclusive, are involved in a greater or less degree. The type, 
then, is called inferior costal. This type is very rarely, if ever, pre- 
sented alone. It is associated with the abdominal. Both types, in 
other words, are represented frequently in the male sex, difi'erent 
persons differing considerably as respects the predominance of one or 
the other type. The third type is called superior costal, and, as the 
title signifies, is characterized by the respiratory movements, being 
especially manifest at the summit of the chest. This type, as will be 
seeli presently, is peculiar to females. Now, a change in the type of 
respiration generally characterizes exaggerated or forced, as contrasted 
with ordinary, breathing. The abdominal type becomes less marked, 
and the inferior costal appears to take its place. This is demonstrated 
by the ingenious researches of Mr. John Hutchinson,^ the correct- 
ness of which may be easily verified by an examination of the nude 
chest in a living male subject. The respiratory movements, exa- 
mined when the respiration is tranquil, and, afterward, when volun- 
tarily increased, present, in the first instance, an abdominal motion 
more or less marked, with or without a certain degree of inferior 
costal motion ; and, in the second instance, the abdominal motion, 
instead of being increased, is diminished, while the inferior costal 
motion is notably increased, a superior costal motion being some- 
times superadded. Mr. Hutchinson was led to think that, with this 
change, the diaphragmatic movements almost ceased. This, how- 

' Recherches sur le mecanisme des mouvements respiratoires. Archives Generales 
de Med ecine, Decern bre, 1842. 

2 Medico-cbiriirgical Transactions, vol. xxix, 1846. 



26 ANATOMY AND PHTSIOLOQY. 

ever, is not the fact, as shown conclusively by Dr. F. Sibson. The 
expansion of the inferior ribs, which is measurably due to the dia- 
phragm, prevents the rising and falling of the abdominal walls from 
being apparent. Nevertheless, it takes place, as may be satisfac- 
torily proved by percussing the lower part of the chest before and 
after a deep inspiration. The evidence of the depression of the 
diaphragm thus afforded, will appear in a subsequent section. 

The intercostal spaces at the lower part of the chest are somewhat 
widened with the act of inspiration, and, conversely contracted with 
expiration. At the summit of the chest, however, the reverse of this 
is the case. The ribs approximate very slightly in inspiration, in 
consequence of each rib being raised slightly more than the one 
above it. 

The intercostal depressions which are apparent at the inferior por- 
tion of the chest laterally and anteriorly, especially in thin persons, 
are most conspicuous in the act of inspiration, and are increased in pro- 
portion to the extent of the inspiratory movements. This is the rule, 
but, according to MM. Beau and Maissiat, exceptions are occasion- 
ally to be observed. 

The respiratory movements in the adult female differ in a re- 
markable manner from those which have been described as belonging 
to the male sex. In the adult female the superior portion of the 
chest presents, in the act of inspiration, an expansion notably greater 
than in males, the movements of the inferior portion of the chest, 
and of the abdomen, being proportionably less prominent. The 
contrast in this respect between the two sexes is striking. " The 
adult male," to quote the language of Dr. Walshe, "seems to the 
eye to breathe with the abdomen and the lower ribs, from about 
the tenth to the sixth ; the adult female, with the upper third of the 
chest alone." In other words, the breathing peculiar to females is 
the superior costal type, while in males it is associated with the 
abdominal^ generally combined, more or less, with the inferior 
costal type. To observe this difference in the two sexes, it is only 
necessary that the attention be directed to the subject when in the 
presence of ladies ; but it is especially conspicuous when the breathing 
is convulsively affected by strong mental emotions, or when these 
emotions are simulated in histrionic performances. Hypothetically, 
two reasons suggest themselves, and have been offered to account 
for these differences in the two sexes — differences which it is of 
importance should be borne in mind with reference to the study of 



THE THORACIC PARIETES. 27 

diseases of the respiratory apparatus. One of these reasons is, that 
nature has in this way provided for the due performance of respira- 
tion during the period of gestation, when the diaphragmatic move- 
ments are mechanically impeded. Boerhaave and Haller, who had 
observed this point of difference (which appears to have been lost 
sight of by more modern writers up to a period quite recent), 
considered it in that light. This, however, is simply adducing a 
final cause. Another reason, more entitled to be called an explana- 
tion, is, that the movements of the diaphragm and lower part of the 
chest become permanently impaired in females by modes of dressing, 
involving compression of the inferior ribs ; and, as a consequence, 
the superior thoracic movements are unnaturally developed. The 
validity of the latter explanation, it is evident, hinges on the ques- 
tion whether the differences be natural or acquired ; and this question 
is to be decided by examining girls and adult females whose waists 
have not been encased in any restraining or contracting apparatus. 
With respect to this point the conclusions at which different observers 
have arrived, are not altogether uniform. Dr. Walshe states that 
he has examined a considerable number of female children, aged be- 
tween four and ten years, who had never worn stays, or any substi- 
tute therefor, who presented, nevertheless, the predominant action 
at the summit of the chest, observable in adult females, the pecu- 
liarity, however, being less than in later years. He states, also, that 
the female agricultural laborer breathes more like a male than the 
town female ; and that during sleep the difference between the sexes 
is less conspicuous. MM. Beau and Maissiat affirm that they have 
observed this peculiarity marked in young girls, and in females from 
the country who had never worn corsets. But, according to their 
researches, the peculiarity does not become apparent till the third 
year of life. Prior to the age just mentioned the type of breathing 
in female as in male children is usually abdominal. Mr. John 
Hutchinson, in his valuable paper already referred to, says he " ex- 
amined 24 girls between the ages of 11 and 14 who did not wear any 
tight dress, and found in them the same peculiarity in ordinary 
breathing." Mr. Francis Sibson^ attributes the peculiarity to modi- 
fications of the chest induced by tight lacing. He states that " the 
form of the chest and the respiratory movements do not differ 
perceptibly in girls and boys below the age of 10." Still, he 

' On the movements of respiration in disease, and on the use of a chest-measurer. 
Med. Chir. Trans of Royal Med. and Chir. Society of London, vol. xxxi, 1S4S. 



28 ANATOMY AND PHYSIOLOGY. 

remarks, '' it is probable that in females, even if tbey wore no stays, 
the thoracic respiration would be relatively greater, and the diaphrag- 
matic iess, than in man." Judging from the foregoing statements, 
by those who, within the past few years, have made the respiratory 
movements the subject of extensive personal investigations, it would 
seem that, although a certain amount of influence may be attributable 
to dress, the difference which has been pointed out is not wholly derived 
from that source. A collection of an extended series of observations 
relative to this point is, however, still a desideratum. 

The respiratory movements are modified by age. This is owing 
mainly to the differences as regards the flexibility and elasticity of 
the costal cartilages which belong to different periods of life. In 
boys, the costal expansion is greater than adults, for the reason just 
stated ; and in old men, when the cartilages become ossified, forming 
with the ribs one unyielding piece, the diaphragmatic movements are 
increased, and the costal proportionably diminished. Between the 
two extremes of life, the character of the respiration will be likely to 
approximate to that belonging to the one or the other, according to 
the proximity of the individual to boyhood or old age. In aged 
persons, whose costal cartilages are ossified, the action of the muscles 
elevating the ribs tells exclusively on their sternal ends ; hence the 
motion of the sternum is marked, and owing to the greater length and 
obliquity of the inferior true ribs, the lower portion of the sternum 
is raised and projected more than the upper portion. An effect 
somewhat similar is produced in cases of permanent expansion of 
the chest from over-distended lung in certain cases of emphysema. 
The costal cartilages, although not rendered comparatively non- 
elastic by ossification, are kept on the stretch by the abnormally 
increased volume of the lung, and the ribs and sternum move up- 
ward in the act of inspiration " as if in one piece." 

Infants present this modification : the abdominal movements are 
less, and the thoracic proportionably greater than in youth after the 
period of infancy is passed. 

To determine with exactitude the amount of the alternate expan- 
sion and contraction of different parts of the chest with the two 
acts of respiration, some method of accurate measurement must, of 
course, be employed. An apparatus for this end has been devised 
by Br. Sibson, which he calls the chest-measurer. It consists of 
several parts, as follows : 1, a brass plate, covered with silk, on 
which the patient lies ; 2, an upright rod, divided into inches and 



THE THORACIC PARIETES. 29 

tenths, to indicate the diameter of the chest ; 3, a horizontal rod, 
moving by a slide on the upright rod, which can be lengthened by 
being drawn out like a telescope ; 4, at the extremity of the latter a 
dial and rack. The rack, when raised by the moving walls of the 
chest, moves, by means of a pinion, the index on the dial. A revo- 
lution of the index indicates an inch of motion in the chest, and 
each division indicates the 100th of an inch. 

By means of an instrument of this description the extent of mo- 
tion of different parts of the chest may be ascertained with minute 
accuracy. It indicates, also, very correctly the relative duration of 
each of the two respiratory acts, and in the latter point of view is 
especially useful. 

In the valuable paper already referred to, Dr. Sibson has given 
the results of a large number of observations on the movements of 
respiration in health and disease. The more important of these re- 
sults, relating to healthy movements, are embraced in the following 
summary : In the healthy, robust male, the movement of the ster- 
num, and of the ribs from the first to the seventh, is from '02 to '07 
inches during an ordinary inspiration, and from '5 or -7 to 2 in. 
during a deep inspiration. The ordinary abdominal movement 
(diaphragmatic), is from -25 to -3 in. ; the extreme from -6 to J in. 
As regards the two sides of the chest compared, the expansion of 
the second ribs is alike on the two sides ; but below, the inspiratory 
movements, both in ordinary and forced breathing, are somewhat 
less on the left than on the right side, especially over the heart. In 
females, when stays are on, the thoracic movement at the second 
ribs, is from '06 to '2 in. ; the abdominal, from '06 to '11 in. When 
the stays are off, the thoracic movement is from -03 to 4 in., and the 
abdominal from '08 to '2 in. The latter observations, as Dr. S. 
remarks, render it certain that the wearing of stays materially in- 
fluences the respiratory movements, lessening the movement of the 
diaphragmatic ribs, and exaggerating that of the thoracic. They 
do not, however, disprove the fact that a natural difference exists in 
the two sexes, which other observations appear to establish. The 
reader, desirous of farther details, will find them in the paper from 
which the above summary is taken. 

The cJiest-measurcr of Dr. Sibson, and other contrivances to deter- 
mine the amount of motion with the same exactness, have the 
disadvantage of bemg more or less complicated and cumbersome. A 
simple graduated tape will suffice to determine, with tolerable 



30 ANATOMY A^^r PHYSIOLOGY. 

accuracy, differences of size, both lateral and anibero-pofBterior, be- 
tween a full inspiration and a forced expiration. But to aBoertain 
by tliis mode the precise degree of motion in ordinaij breathing is 
Tcry difficult, tbe results Tarying very considerably aoeording to the 
degree of tension "witb wMcb the tape is held. This difficnlty wSH be 
at once apparent to any one who attempts to employ this more simple 
instrument for that end. The results are only remote approximar 
tions to accuracy. Dr. Quain has endeavored to obviate the doMcaitj 
attending the use of the -simple tape, without impaiiing much its 
simplicity, in the instrument contrived by him, which he calls a 
stetJiometer. It consists of a cord connected by an axle with an 
index which it is capable of moving over a graduated diaL The cord 
being extended from a fixed point on the chest to another, the extent 
of the respiratory movement will be manifested by the tension made 
on the cord being communicated to the index, and shown in figures 
on the dial, from which it can be read off in factions of an inch.^ 

Practically, however, it is not of much importance to determine 
with mathematical accuracy the extent of the thoracic and abdominal 
movements with reference to the phenomena of disease. The eye 
will answer for an estimation somewhat rough, but sofiiciently exact 
for clinical purposes. 

Intra-thoracic disease may be evidenced by marked dimin::::! :: 
the movement of a portion of the chest. This is oflten observt 1 :i 
tuberculosis of the lungs, at the superior part of the chest 
side ; oftener in females than in males, in consequence of the , . ; 
mobility iQ them naturally in that situation. Local empL- : 

the lungs may also produce a simikr effect, axscompaLir : 7 ..:. 
abnormal protrosion or bulging of a portion of the diest. 

The respiratory movements, as has been seen, are :.':■:.;:-_::: .".7 
increased in pregnancy, and in various affections which comprizii^r 
the function of hsematosis. When this increase is bat modera:T, :: 
is stated 'bj M^I. Beau and Maissiat that the moT^nenls in one - 
dividual wiH differ from those in another, according to the tyj- : : 
breathing natural to the iudividiial. Thus, if the type be pn: -j 
abdominal, the abdominal movements alone will be inoreased; In: 1: 
it be inferior costal, as well as abdominal, the movements of thelc~f : 
ribs will be conspicuous ; and if, as in females, it be siqperior cos: ... 
the exaggeration will be found to affect chiefly the siq»erior p©r::;i. 
of the chest. In cases, however, in which the sense of the wax: : : 

' Coxeter's Catalogne of Siirsical Instraments aud 



THE THORACIC PARIETES. 31 

respiration, or dyspnoea, is intense, and the breathing exceedingly 
labored, the three types may be simultaneously represented. But, 
under these circumstances, the thoracic muscles more especially are 
brought into active requisition, and in order to effect the utmost pos- 
sible enlargement of the chest, various muscles are employed which 
are capable indirectly of aiding in respiration. An erect or sitting 
posture, being most favorable for the action of these muscles, is also 
selected. These changes will claim attention in connection with the 
symptomatology of the diseases in which they are exemplified. 

The rhythmical succession of the two acts of respiration, in other 
words the order of their alternation, relative duration, etc., and the 
degree of power belonging to each act, involve certain points of 
interest, which have also important relations to the study of diseases. 

Of the two acts, inspiration, in ordinary breathing, is accomplished 
by the active exertion of muscular power. An ordinary expiration 
follows as a consequence of the suspension of the muscular force 
which has occasioned the preceding inspiration, being due chiefly to 
the weight of the abdominal organs, which, with the elasticity of the 
abdominal walls, press upward the diaphragm ; together' with the 
elasticity of the ribs, costal cartilages, and the contained pulmonary 
organs. It is only when the expiration is voluntarily increased or 
prolonged, or when it is spasmodically exerted, as in coughing or 
sneezing, that a notable degree of muscular power is exerted in this 
act. But the co-operation of the muscles with the several circum- 
stances that have been mentioned, determined either by volition or 
spasmodic action, renders the act more forcible than that of inspira- 
tion. Mr. Hutchinson,^ by a series of experiments, showing the force 
of the two acts, respectively, as indicated by the elevation of a 
column of mercury, arrived at the result, that the expiratory, with 
muscular co-operation, exceeds the inspiratory by one-third. This 
excess of force he thinks is about equal to the elasticity which is 
brought to bear on the former act. The greater power of expiration 
when aided by the will, is manifest in the application of this respira- 
tory act to various uses, such as singing, coughing, playing on wind 
instruments, glass-blowing, etc. 

From the facts which have been stated relative to ordinary 
breathing, it follows, that the expiratory movement commences at the 
instant the inspiratory ceases. The latter is merged into the former, 
with scarcely any appreciable interval between the two. So far as 

' Op. cit. 



32 AXATOMY AND PHYSIOLOGY. 

the expiratory movement is readily appreciable, it appears to be con- 
siderably sborter than the inspiratory, and an interval of some dura- 
tion seems to elapse, after the completion of an expiratory act, before 
the next inspiration commences. This interval, however, is more 
apparent than real. After the expii-atory movement ceases to be 
obvious, the pulmonary organs probably continue to contract, in a 
manner not readily appreciable, nearly if not quite to the recurrence 
of the act of inspiration, unless restrained by a volimtary effort. 
This is illustrated sometimes in cases of catarrh or mild bronchitis, in 
which a laryngeal rale accompanies the entire act of expiration, the 
lungs not being affected so as to cease to represent the amount of 
collapse which takes place in health. As indicated by the continu- 
ance of this rdhj the expiratory movement is prolonged, almost, or 
even quite, to the subseqtfent act of inspiration. The latter part of 
this movement is due, not to primary contraction of the thoracic 
parietes, but to continued collapse of the lung, together with the 
pressure of the abdominal viscera. Dr. TTalshe estimates the interval 
between the eiTd of one expiration and the beginning of the next 
inspiration, at one-tenth of the jDcriod occupied by both acts. But if 
we were to be guided by the cessation of the obvious abdominal and 
thoracic movements, the interval would be considerably greater. 

Judging from a cursory examination, or from attention to one's 
own respiration, the act of expiration appears shorter in duration than 
that of inspu'ation. The two acts, however, as determined by the 
chest-measurer of Dr. Sibson, in ordinary respiration, are generally 
equal in duration. When a difference exists, the expiration is oftener 
prolonged. This is apt to be the case in the tranquil breathing of 
women and childi'en. It characterizes also the respiration in old age. 
In hurried breathing, in females especially, the expiratory act be- 
comes relatively lengthened. 

xs'either the inspiratory nor the expiratory act is performed with 
a uniform degree of rapidity. The inspiration is at first slow, 
becomes gradually quicker, and again is retarded toward its close. 
The expiratory act is performed more quickly at first, and during 
the latter part more slowly than the inspii'atory. These facts will 
in a measure account for certain differences in character which dis- 
tinguish the expiratory from the inspiratory sound, as determined by 
auscultation in health and disease. 

Deviations from the natural rhythm of the respiratory movements 
will be found to furnish characteristics of some forms of disease. In 



THE THORACIC PARIETES. 33 

cases of obstruction seated in the larynx, or other parts of the air- 
passages, the expiration is morbidly prolonged. In emphysema 
involving an abnormal dilatation of the air-cells, and diminished 
elasticity of the lungs, the expiration becomes obviously much longer 
than the inspiration. On the other hand, a shortened and quickened, 
or spasmodic inspiration, is a significant symptom of some affection of 
the nervous system, occurring in some cases of hysteria, and also under 
circumstances in which it is of a much more serious import, denoting 
a morbid condition of great gravity affecting that portion of the 
nervous centre (medulla oblongata) which presides over the involun- 
tary acts of respiration. The writer has called attention to the 
importance of this change in the rhythm of respiration in cases of 
continued fever, which will be found to precede often, in that disease, 
the occurrence of sudden coma.-^ 

Finally, the size of the chest is a point remaining to be noticed. 
This may be estimated by circular measurement with a graduated 
tape. Persons differ considerably in this particular. The limits 
of variation in 994 cases in which the circumference was ascer- 
tained by Mr. Hutchinson, were from 30 to 40J inches. Dr. 
Walshe fixes the average size at about 33 inches ; but the normal de- 
viations being so great, it is of little practical utility to determine a 
standard by taking the mean of a series of examinations. This 
point, clinically, is not of much importance, especially as the re- 
searches of Mr. Hutchinson show that the breathing capacity of the 
lungs dependent on the movements of the chest, bears no constant 
proportion to its size. Formerly it was supposed that contracted 
dimensions of the chest gave rise to a predisposition to diseases of the 
respiratory apparatus, more especially tuberculosis of the lungs ; but 
it is now pretty well ascertained that little or no tendency to that, 
or other forms of disease, is derived from this source. In determining 
variations in the size of the chest, either by measurement, or by 
the eye, with reference to the evidences which may be thereby 
afforded of the existence of disease, we do not take the dimensions of 
the entire chest as the standard, but institute a comparison of one 
side with the other. This being the case, the capacity of the thorax 
proper to the individual is a matter of minor importance. 

' Clinical Reports on Continued Fever, etc., 1852. 
3 



32 ANATOMY AND PHYSIOLOGY. 

the expiratory moyement is readily appreciable, it appears to be con- 
siderably shorter than the inspiratory, and an interval of some dura- 
tion seems to elapse, after the completion of an expiratory act, before 
the next inspiration commences. This interval, however, is more 
apparent than real. After the expiratory movement ceases to be 
obvious, the pulmonary organs probably continue to contract, in a 
manner not readily appreciable, nearly if not quite to the recurrence 
of the act of inspiration, unless restrained by a voluntary effort. 
This is illustrated sometimes in cases of catarrh or mild bronchitis, in 
which a laryngeal rale accompanies the entire act of expiration, the 
lungs not being affected so as to cease to represent the amount of 
collapse which takes place in health. As indicated by the continu- 
ance of this rdle^ the expiratory movement is prolonged, almost, or 
even quite, to the subsequent act of inspiration. The latter part of 
this movement is due, not to primary contraction of the thoracic 
parietes, but to continued collapse of the lung, together with the 
pressure of the abdominal viscera. Dr. Walshe estimates the interval 
between the end of one expiration and the beginning of the next 
inspiration, at one-tenth of the period occupied by both acts. But if 
we were to be guided by the cessation of the obvious abdominal and 
thoracic movements, the interval would be considerably greater. 

Judging from a cursory examination, or from attention to one's 
own respiration, the act of expiration appears shorter in duration than 
that of inspiration. The two acts, however, as determined by the 
chest-measurer of Dr. Sibson, in ordinary respiration, are generally 
equal in duration. When a difference exists, the expiration is oftener 
prolonged. This is apt to be the case in the tranquil breathing of 
women and children. It characterizes also the respiration in old age. 
In hurried breathing, in females especially, the expiratory act be- 
comes relatively lengthened. 

Neither the inspiratory nor the expiratory act is performed with 
a uniform degree of rapidity. The inspiration is at first slow, 
becomes gradually quicker, and again is retarded to-^rard its close. 
The expiratory act is performed more quickly at first, and during 
the latter part more slowly than the inspiratory. These facts will 
in a measure account for certain differences in character which dis- 
tinguish the expiratory from the inspiratory sound, as determined by 
auscultation in health and disease. 

Deviations from the natural rhythm of the respiratory movements 
will be found to furnish characteristics of some forms of disease. In 



THE THORACIC PARIETES. 33 

cases of obstruction seated in the larynx, or other parts of the air- 
passages, the expiration is morbidly prolonged. In emphysema 
involving an abnormal dilatation of the air-cells, and diminished 
elasticity of the lungs, the expiration becomes obviously much longer 
than the inspiration. On the other hand, a shortened and quickened, 
or spasmodic inspiration, is a significant symptom of some affection of 
the nervous system, occurring in some cases of hysteria, and also under 
circumstances in which it is of a much more serious import, denoting 
a morbid condition of great gravity affecting that portion of the 
nervous centre (medulla oblongata) which presides over the involun- 
tary acts of respiration. The writer has called attention to the 
importance of this change in the rhythm of respiration in cases of 
continued fever, which will be found to precede often, in that disease, 
the occurrence of sudden coma.-^ 

Finally, the size of the chest is a point remaining to be noticed. 
This may be estimated by circular measurement with a graduated 
tape. Persons differ considerably in this particular. The limits 
of variation in 994 cases in which the circumference was ascer- 
tained by Mr. Hutchinson, were from 30 to 40J- inches. Dr. 
Walshe fixes the average size at about 33 inches ; but the normal de- 
viations being so great, it is of little practical utility to determine a 
standard by taking the mean of a series of examinations. This 
point, clinically, is not of much importance, especially as the re- 
searches of Mr. Hutchinson show that the breathing capacity of the 
lungs dependent on the movements' of the chest, bears no constant 
proportion to its size. Formerly it was supposed that contracted 
dimensions of the chest gave rise to a predisposition to diseases of the 
respiratory apparatus, more especially tuberculosis of the lungs ; but 
it is now pretty well ascertained that little or no tendency to that, 
or other forms of disease, is derived from this source. In determining 
variations in the size of the chest, either by measurement, or by 
the eye, with reference to the evidences which may be thereby 
afforded of the existence of disease, we do not take the dimensions of 
the entire chest as the standard, but institute a comparison of one 
side with the other. This being the case, the capacity of the thorax 
proper to the individual is a matter of minor importance. 

* Clinical Reports on Continued Fever, etc., 1852. 
3 



34 ANATOMY AND PHYSIOLOGY. 



II. Pulmonary Organs. 



The lungs are the light spongj bodies contained within the chest, 
in which are effected the blood-changes constituting the function of 
hsematosis. These organs are double, consisting of the right and 
left lung, each occupying a lateral half of the cavity of the thorax. 
The lung on each side is provided with a distinct membranous 
envelope — the pleura — which, after furnishing a covering for the 
pulmonary surface, is reflected upon the thoracic wall, and forms 
a shut sac, presenting the same arrangement as the serous mem- 
branes in other situations. The two pleural sacs are in contact at 
the median line, forming, by their juxtaposition, the mediastinal 
partition, or septum, dividing the two sides of the chest. Joined 
directly beneath the sternum, they diverge to form the anterior 
mediastinum, which encloses the remnant of the thymus gland; 
approximating, and becoming united, they again separate, forming 
the middle mediastinum, which contains the pericardial membrane 
enclosing the heart ; and by a third separation is formed the poste- 
rior mediastinum, through which pass the descending aorta, thoracic 
duct, etc. The portion of this membrane investing the lungs is 
called the pulmonic or visceral pleura ; and that lining the walls of the 
chest, the costal or parietal pleura. A third portion, forming a cover- 
ing for the floor of the thoracic cavity — the diaphragm — is called the 
diaphragmatic pleura. Between the free surfaces of the two former 
portions in each lateral half of the chest, is what is termed the cavity 
of the pleura — erroneously so called, inasmuch as the free surfaces 
being in contact, there does not exist, strictly speaking, a cavity. 
Between these surfaces, within the shut sac of the pleura, liquid 
effusion takes place in pleurisy, and hydro-thorax, accumulating, in 
some cases, to the amount of several pounds, compressing the lung 
into a small solid mass, and producing changes in the external 
conformation of the chest, which have been already noticed, viz., 
enlarging its size, pushing outward the intercostal spaces, elevating 
the ribs from their oblique towards a horizontal direction, widening 
the distance between them, and compromising more or less the 
mobility of the affected side. 

The parietal or costal portion of the pleura is thicker than the 
visceral or pulmonary portion, and than that covering the dia- 
phragm. The areolar tissue uniting the membrane to the parts 



PULMONARY ORGANS. 85 

wMcli it invests, called the subserous areolar tissue, is more abun- 
dant and looser in the former situation, and, consequently, the serous 
membrane is more easily detached from the walls of the chest than 
from the surface of the lungs. This, probably, explains a fact 
pertaining to inflammation of the pleura, viz., that the inflammatory 
action is more intense, and the products of inflammation are found 
to be more abundant, on the costal, than on the pulmonary surface.. 

The lung on either side varies in size according to the quantity of 
air which it contains, and, of course, its volume is alternately in- 
creased and diminished with the successive acts of inspiration and 
expiration. Its form is conoidal, the base being downward. The 
portion in contact with the walls of the chest extends lower than the 
central portion, in consequence of the arched or vaulted form of the 
floor of the chest — the diaphragm. Between the sides of the arch 
or vault formed by the diaphragm and the thoracic walls, is a space 
deeper behind than in front, which receives the inferior shelving 
border of the lungs. Thus at the lower part of the chest, on each 
side, a margin of lung intervenes between the diaphragm and the 
walls of the chest, more especially in the act of expiration, when the 
convexity of the diaphragm is greatest. 

Owing to the fact already stated that the vertical diameter of the 
right side of the chest is less than that of the left, the right lung is 
shorter than its fellow. Transversely, however, the diameter of the 
right lung exceeds that of the left. This accords with a fact already 
stated, viz., that the semi-circumference of the right side usually 
exceeds that of the left by about half an inch. But there is another 
reason for the latter disparity. The situation of the heart is such 
that a portion of this organ encroaches somewhat on the left thoracic 
cavity, at the expense of the lung on that side. An irregularly 
triangular space between the fourth costal cartilage and the sixth 
rib, is occupied by the heart, uncovered by the lung and in contact 
with the chest. Vertically, this space averages, in the adult, about 
two inches ; and horizontally, from the centre of the sternum, it 
extends about two and a half inches to the left. Overlapped by the 
lung, the heart extends still farther into the thoracic space, viz., ver- 
tically, from the third to the sixth costal cartilages ; and, trans- 
versely, nearly to the nipple. In consequence of its lesser transverse 
diameter, together with the encroachment of the heart, the left lung 
is smaller in volume, notwithstanding, measured in a perpendicular 
direction, it is longer than the right lung. The right lung exceeds 
the left in weight as well as in volume. 



36 AXATOMT AND PHYSIOLOGY. 

When free from disease, or the effects of disease, the lung is de- 
void of any direct connection with the surrounding parts, excepting 
the point at which it is connected with the bronchia, the blood- 
vessels, lymphatics, and nerves which enter it to communicate, 
severally, with corresponding structures forming portions of the 
pulmonary organs. United by areolar tissue, including lymphatic 
glands, and enclosed in a sheath formed by a reflection of the 
pleura, the parts just enumerated compose what is termed the root 
of the lung. By the root^ thus constituted, the lung, on each side, 
is, as it were, suspended or fixed, within the chest, the surface of the 
remainder of the organ being entirely free, in health, or adherent, to 
a greater or less extent (as is very frequently the fact), in conse- 
quence of morbid attachments. In its situation, the root of the lung 
is about equidistant between the base and apex. 

The upper extremity of the lung, or apex, extends above the cavity 
of the chest, forming a blunted point, rising an inch and a half higher 
than the first rib. The latter fact is involved in the determination 
of tuberculous disease, or phthisis, in its incipient stage ; that affec- 
tion generally attacking, primarily, the superior extremity of the 
lung on one side. 

The division of the lungs into lohes is a point of considerable im- 
portance in the study of certain pulmonary diseases. It is made by 
deep fissures extending in an oblique direction from above downward. 
The left lung presents a single fissure ; the right has one fissure 
extending, like that of the left lung, around the whole circumference 
of the organ, and a second running from the anterior border a short 
distance only upward and backward. Thus divided, the left lung is 
said to consist of two lobes called the upper and lower ; and the right 
lung of three, called the upper, lower, and middle lobes. The middle 
lobe of the right lung, however, is hardly entitled to be ranked as a 
separate lobe, but is '' an angular piece separated from the anterior 
and lower part of the upper lobe." It is of importance with refer- 
ence to the diseases, which are to be subsequently considered, to note 
the situation of the fissures dividincr the lunors into lobes, as indicated 
by corresponding imaginary lines on the exterior surface of the 
chest. Posteriorly, they commence about three inches below the 
apex of the lung. Indicated on the chest, the line corresponding to 
their direction takes its departure at a point not far from the 
vertebral extremity of the spinous ridge of the scapula. On the left 
side the boundary line between the two lobes passes from the point 



PULMONARY ORGANS. 37 

just named obliquely downward to the intercostal space, between the 
fifth and sixth ribs, the anterior point of division falling a little to 
the right of a vertical line passing through the nipple. On the 
right side, the line marking the upper border of the lower lobe, 
passes obliquely downward to the space between the fifth and sixth 
costal cartilages. The line dividing the middle and upper lobes 
passes from the fourth cartilage in a direction upward and outward, 
for a distance varying considerably in difierent individuals. It fol- 
lows from these statements that a small strip only of the lower lobe 
on each side is contained in the anterior portion of the chest, the 
greater portion being situated posteriorly. The physical signs, 
therefore, of morbid changes in the condition of the lower lobe are 
presented mainly in the middle and lower portions of the chest be- 
hind. It is very necessary to bear this in mind in examinations with 
reference to inflammation of the lung (pneumonitis), which, as will 
be seen hereafter, in a large proportion of cases, in the adult, is 
limited to the lower lobe. Inattention to this point may lead the 
medical practitioner to overlook that disease, limiting his examination 
to the anterior portion of the chest in cases in which the evidences 
of its existence are sufiiciently apparent posteriorly. 

The interlobar fissure, according to Rokitansky, becomes changed 
in its direction by the affection called emphysema seated in the upper 
lobe, tending under these circumstances to a vertical line. 

The foregoing are the more important of the circumstances per- 
taining to the situation of the lungs, and the relations of their several 
parts, which claim notice from their pathological bearings. But an 
analysis of the anatomical structure of these organs will develope 
numerous points which are to be taken into account in studying their 
diseases. 

In addition to bloodvessels, nerves, and lymphatics, which are 
common to most of the important organs of the body, the lungs are 
composed of the divisions and subdivisions of the hronchice or the 
bronchial tubes, and the air-cells or vesicles. These, combined, give 
to the lungs their distinctive traits of structure. The bronchi^ after 
penetrating the lung, divide and subdivide in all directions, the divi- 
sions generally being of the kind called dicJiotomous, i. e. consisting 
of two branches, the mode of division most favorable for the speedy 
transmission of air. As the branches increase in number, they 
diminish in size, until, at length, they become extremely minute, and, 
finally, the ultimate ramifications, the capillary bronchial tubes, 



40 ANATOMY AND PHYSIOLOGY. 

enlargement of tlie air-cells, or vesicles, either by coalescence or 
dilatation. 

It remains to notice certain points pertaining to tlie structure, 
arrangement, and mutual relations of the bronchial tubes, and air- 
cells. 

The general course and distribution of the bronchial tubes in the 
several lobes have been already described. The branches, succes- 
sively and severally, end in double divisions, and with this rapid mul- 
tiplication in number there is a corresponding diminution in size, down 
to the minute lobular bronchial tubes, which, after penetrating the 
lobules, subdivide into the terminal branches, — the bronchioles, or 
bronchial capillaries.^ In referring to different sets of the bronchial 
tubes as the seats of disease, or of physical signs, it is customary to 
consider them as embraced in three classes, viz., the larger, the 
smaller, and the capillary tubes. In designating the site of morbid 
appearances after death it is sometimes convenient to indicate the 
divisions as those of the first, second, third, and fourth diameters : 
that is, the series of double, branches are thus enumerated in the 
order in which they are given off. These are the larger bronchial 
tubes, the smaller being the subsequent series, inclusive of those 
passing to the lobules. 

The larger bronchial tubes are composed of a fibrous membrane, 
containing irregularly shaped cartilaginous plates, the latter taking 
the place of the incomplete rings of cartilage which characterize 
the air-tubes exterior to the lung. These cartilaginous plates are 
situated especially at the bronchial divisions. They embrace, also, 
a layer of circular muscular fibres, of the kind called smooth or un- 
striped, belonging to the muscular system of organic, as distin- 
guished from animal, life. This anatomical element is the seat of 
the affection known as asthma, and is sometimes involved in certain 
symptoms incidental to inflammation and irritation of the bronchial 
tubes. 

They are lined by mucous membrane, covered with a layer of 
ciliated, cylindrical, or columnar epithelium, the object of the latter 
being, manifestly, to propel, and thus assist in the removal, by ex- 
pectoration, of the secretions furnished by the mucous follicles in 
health and disease, as well as various morbid products formed within 



' Called by Mr. Rainey, the "intercellular passages." (Trans. Royal Med. and Chir. 
Society, 1845.) 



PULMONARY ORaANS. 41 

or poured into the tubes. This membrane is the seat of inflamma- 
tion in ordinary bronchitis, and of irritation in pulmonary catarrh. 

The smaller bronchial tubes present marked changes. The fibrous 
membrane, forming their basis, becomes thinner and thinner as the 
tubes diminish in size ; the cartilaginous plates are less and less 
numerous ; the mucous membrane is more and more attenuated, and, 
at length, when the calibre of the tubes is reduced to about a twen- 
tieth of an inch, the cartilaginous plates have disappeared, and the 
mucous and fibrous layers appear to have coalesced, forming a single 
thin membrane. The inner surface, however, still presents ciliated 
epithelium. 

Finally, ramifying within the lobules, the ultimate bronchia termi- 
nating in the air-cells, as respects size, are truly capillary, having 
a diameter varying from one-fifteenth to one-thirtieth of an inch. 
These capillary tubes present still more important changes in struc- 
ture. The membrane constituting their walls is exceedingly thin, 
and its inner surface does not present epithelium, cylindrical and 
ciliated, but it is that variety called indifferently squamous, tes- 
sellated, or pavement epithelium. The pulmonary capillaries, in 
fact, lose the characters which belong to the bronchial tubes, and 
assume the structure of the air-cells, with which they are imme- 
diately connected. 

The anatomical changes which thus characterize different divisions 
of the bronchial tubes, are in accordance with certain striking facts 
pertaining to diseases of the respiratory apparatus. A principle of 
conservatism is often evidenced in the history of diseases by their 
reluctance, so to speak, to pass from one part to another part con- 
tinuous, or contiguous, but presenting differences of structure. The 
latter appear to constitute the restraining barrier. This principle 
is exemplified in the fact that ordinary bronchitis is limited to the 
larger bronchial tubes, rarely extending to the smaller, to constitute 
what is incorrectly styled capillary bronchitis. The latter variety 
of the disease, as will be seen hereafter, is vastly more severe and 
dangerous. 

Conversely, an inflammation seated in the air-cells and capillary 
tubes (pneumonitis), is usually limited to these parts, not extending 
to the branches of the bronchia^ which, although in direct communi- 
cation, are protected by differences in structure. 

The air-cells, or vesicles, are the minute cavities in which the 
bronchial tubes are said to terminate. Their diameter varies from 



42 ANATOMY AXD PHYSIOLOGY. 

^^_ to 7V of an incli. After birtli they are never free from air, and 
their size will depend on their degree of distension, this being, of 
course, considerably greater after an act of inspiration than after 
expiration. They are attached to the extremities, and also along 
the sides of the terminal branches of the bronchioles, or capillary 
bronchial tubes, with which they communicate by free openings. 
Microscopical observers have differed as to the existence of direct 
lateral communications between the cells. According to the best 
authorities, they do not communicate with each other, except indi- 
rectly, through the bronchioles, or capillary bronchial tubes. Their 
connection, however, with the latter is such that, although not direct, 
the communication is free. 

A single bronchiole or terminal branch with its attached cells may 
be considered to form a common space, subdivided into numerous 
sections or alveoli. It is stated that the air-cells are larger toward 
the surface of the lung, and also toward the edges, than in the inte- 
rior. Their size increases with age, and they are smaller in females 
than in males. Their walls possess much strength, shown by their 
not being easily ruptured by artificial inflation. 

The air-cells are surrounded by yellow elastic fibres, which give to 
the lungs a considerable degree of elasticity. This is shown by the 
fact that they collapse, in a marked degree, when the cavity of the 
chest is opened. 

It is within the cells that the atmospheric air received by inspira- 
tion exerts its effects on the blood. The pulmonary artery entering 
the lobes in company with the bronchi, divides and subdivides, with- 
out anastomosing, its branches accompanying the air-tubes, until it 
ends in a very fine capillary network ramifying on the walls of the 
cells. Here, also, commence the various radicles and branches, which, 
pursuing a retrograde course, like that of the arteries, collect the 
oxygenated blood and convey it to the left auricle. The blood 
within the capillary meshes surrounding the cells is brought into suf- 
ficient proximity to the air contained in the latter, for that inter- 
change of principles to take place, by endosmosis and exosmosis, 
which is concerned in hsematosis. 

The air-cells and capillary tubes, together with the bloodvessels, 
nerves, and lymphatics, united by areolar tissue, constitute the pul- 
monary parenchyma, or the substance of the lungs. The cells and 
capillary tubes are the parts affected by inflammation in pneumonitis. 
Abnormal distension of the cells and capillary tubes, with or without 



PULMONARY ORaANS. 43 

atrophy and consequent destruction of more or less of the walls, 
giving rise to coalescence, constitutes the lesion in emphysema of 
the lungs„ in the form in which it usually occurs. 

It will be seen hereafter that some of the most important of the 
physical, signs of diseases within the chest have relation to anatomical 
points which the foregoing description has embraced. 

With the enlargement of the chest in inspiration the lungs are 
dilated, by the pressure of the atmosphere filling the bronchial tubes 
and air-cells. The expansion of the lungs is attended by a certain 
amount of movement of the two pleural surfaces (the pulmonic and 
costal) remaining in contact, upon each other. This takes place 
especially at the inferior portion of the chest. As a provision against 
any injurious effects of the friction incident to this movement, which 
must involve a considerable degree of force, the free surfaces of the 
pleura are remarkably smooth, polished, and kept moist by the pre- 
sence of a small quantity of liquid. Hence the two portions of the 
membrane glide over each other with the two acts of inspiration, not 
only without injury, but noiselessly. But it is otherwise in some 
cases, in which these surfaces are rendered rough or irregular by 
morbid products. The gliding movements are, under these circum- 
stances, accompanied by friction sounds, which become the signs of 
disease. These sounds, as might be expected, are most likely to be 
produced where the movements of the thorax and the gliding of the 
pleural surfaces are greatest, viz., at the lower portion of the chest. 

The movements upon each other of the pleural surfaces must be 
limited by morbid adhesions, more or less extensive, of these surfaces, 
which are found to exist in the larger proportion of bodies examined 
after death ; and in certain cases, in which the costal and pulmonic 
pleurse are universally adherent in consequence of general pleurisy, 
they must, of course, be entirely arrested. The latter condition it 
might be presumed would interfere with the expansion of the chest. 
Observations, however, show that this is not the fact. Mr. Hutch- 
inson has given an account of a case in which there was not a square 
inch of the pleural surfaces, on one side of the chest, that was not 
firmly united ; nevertheless in this case the expansion of the chest 
was in no degree diminished. 

The quantity of air contained within the lungs not only varies 
greatly in difierent persons, but in the same person is constantly 
fluctuating within certain limits. It is difiicult to determine these 
limits with exactitude, but in its pathological bearings this is not 



44 ANATOMY AND PHYSIOLOGY. 

a matter of importance. The quantity after an inspiration is of 
course greater than that after an expiration, just in proportion as 
the amplitude of the chest is increased by the former, and diminished 
by the latter of these acts {vide supra). Owing to the control which 
the will can exert over the breathing movements, much will depend 
on the influence of volition. Mr. John Hutchinson, in a paper to 
which reference has already been made more than once, has given 
the results of a large number of experiments to determine the 
quantity of air expelled from the lungs by a forcible act of expiration 
succeeding the fullest possible inspiration. This he considers a test 
of what he terms the vital capacity of the lungs. By means of an 
instrument called the spirometer^ the quantity of air which a person 
is able to receive into and expel from the lungs is ascertained. The 
results of these experiments it is evident do not enable us to de- 
termine the quantity of air received and expelled in habitual respira- 
tion, in other words, the ordinary breathing capacity of the lungs. 
Kor do they assist us in determining the absolute quantity of air 
which the lungs are capable of containing, since a residual quantity, 
varying in different indi\dduals, remains after the most forcible act of 
expiration. Nevertheless the results obtained by Mr. Hutchinson 
are interesting. The vital capacity, in the sense in which this 
expression is used by Mr. H., is a constant quantity in each indi- 
vidual ; that is, each person possesses the ability to expel a certain 
number of cubic inches of air from the lungs, and, assuming that he 
remains free from disease, each person, under circumstances equally 
favorable, will be found to be able to expel at different trials about 
the same quantity. From a very large number of observations made 
on persons of different occupations supposed to be in good health, 
Mr. H. ascertained that the quantity of expired air does not depend 
on the size of the chest, but sustains a fixed relation to the height of 
the individual. The law of this relation deduced from an immense 
number of cases is the following : " For every inch of height (from 
5 ft. to 6 ft.) eight additional cubic inches of air at 60° are given 
out by a forced expiration." 

The reason for this relation to height Mr. H. confesses his inability 
to give. The fact, of course, involves the existence of some circum- 
stances pertaining to the conformation or movements of the chest, 
which enables individuals in proportion to their height to increase, 
and diminish, with the alternate respiratory acts, the amplitude of 
the chest. In other words, the vital capacity is another name for 



PULMONARY OEGANS. 45 

the breathing capacity, dependent on the extent to which the chest 
may be expanded with the act of inspiration, and contracted with the 
act of expiration. Dr. Hodgkin at'tributes it to the "increased 
length of the dorsal portion of the spinal column." Dr. Sibson offers 
as an additional reason the greater length and obliquity of the ribs 
in proportion t^ the stature, a fact which gives to a narrow-chested 
tall man a greater range of motion, and consequent breathing capa- 
city, than belong to a short man with a chest of greater depth. 
These explanations seem probable. A relation less constant was also 
found to exist between the vital capacity and the weight of indivi- 
duals. 

Mr. Hutchinson supposes that the employment of the spirometer 
may be made serviceable in determining the existence of thoracic 
disease. If the vital capacity taken in connection with the height 
and weight of an individual be considerably below the average, some 
morbid condition compromising the pulmonary organs may be sus- 
pected. But the evidence is only presumptive, for the vital capacity 
may be reduced by various causes, compromising the muscular power 
with which the respirations are carried on irrespective of thoracic 
disease. This must be the case if even slight fatigue of the respi- 
ratory muscles will affect the result, and it is stated by Mr. H. that 
"if more than three observations are consecutively made at one time, 
the number of cubic inches of air will, from fatigue, generally be 
found to decrease." The fact is shown by some observations made 
with reference to this point, and reported by Dr. Wm. Pepper in 
a communication contained in the American Journal of Medical 
Sciences, April, 1853. 

The consideration just stated, together with the fact, that the 
variations in different persons within healthy^ limits is very great, 
and also the fact, that even when presumptive evidence of thoracic 
disease is afforded, it gives no information respecting the nature or 
seat of the affection, will probably prevent this from becoming an 
important means of examination with reference to diseases of the 
respiratory apparatus. 

' To illustrate the wide interval between extremes in healthy persons, in a series of 
cases reported by Dr. Wm. Pepper (Am. Jour, of Med. Sciences, April, 1853), in one 
person 6 ft. in height the vital capacity was 151 cubic inches, and in another person 
5 ft. IO5 inches, it amounted to 202| cubic, inches. 



46 ANATOMY AND PHYSIOLOaY. 



III. Trachea, Bronchi, and Larynx. 

The trachea, bronchi, and larynx, are separate portions of the 
canal, or tube leading from the pharynx to the lungs, trasversed by 
the air in its passage to and from the latter organs. The larynx 
in addition contains the organs which chiefly compose the vocal ap- 
paratus. The three divisions require separate consideration. 

Trachea. — This portion of the tube extends from opposite the 
fifth cervical to the third dorsal vertebras . It pursues a vertical 
direction, from the larynx to the point last mentioned, where it ends 
by dividing to form the two bronchi. According to Cruveilhier, it is 
slightly deflected to the right at its lower extremity. It is from four 
to five inches in length, varying with the movements of the head and 
neck ; and its diameter is from three-fourths of an inch to an inch in 
the adult male, being somewhat smaller in the female. 

The calibre is generally enlarged at its lower extremity, where it 
bifurcates. It is composed of from fifteen to twenty cartilaginous 
rings, with membranous interspaces. The rings, however, are not 
complete, forming only about four-fifths of a circle. The deficient 
portion of each ring is situated posteriorly, and the connecting sub- 
stance is membranous. The posterior one-fifth or membranous part 
of the tube is flattened. 

The anatomical constituents of the trachea in addition to the car- 
tilages are : 1st, a membrane of white inelastic fibres, containing also 
longitudinal yellow elastic fibres, most abundant posteriorly, by 
means of which the tube resumes its normal dimensions after having 
been stretched or compressed ; 2d, fibres constituting the trachealis 
muscle, which enter into the composition of the posterior flattened 
portion, extending from one extremity of the incomplete cartilagi- 
nous rings to the other, and attached, also, to the membranous 
interspaces between the rings. By the contraction of these muscular 
fibres the walls of the trachea may be rendered tense, and its calibre 
diminished; 3d, areolar tissue, forming here, as elsewhere, the 
medium of the union of the difi*erent structures; 4th, mucous 
membrane, provided with columnar ciliated epithelium and glandular 
follicles, the latter being most numerous on the posterior surface, — a 
fact which perhaps explains the greater liability of the membrane 
to become ulcerated in this situation. 



TRACHEA — BRONCHI. 47 

Surrounding tlie trachea, especially the thoracic portion, are lym- 
phatic vessels and numerous lymphatic glands. The latter are liable 
to become enlarged by disease, and compress the air-tube so as to 
modify the sounds produced by the current of air to and fro with the 
two acts of respiration, and, in some instances, give rise to obstruc- 
tion sufficient to occasion results more or less serious. 

The anatomical construction of the trachea is such that it conforms 
readily to the varied movements of the head and neck, preserving in 
all positions a free channel through which the lungs receive the con- 
stant supply of atmospheric air necessary to the continuance of life. 

The trachea is rarely attacked by disease independently of other 
parts of the respiratory apparatus. The mucous membrane in this 
situation is the seat of ulcerations in a certain proportion of cases of 
tuberculosis of the lungs, and in typhoid fever ; it is involved in 
catarrhal and inflammatory affections, which frequently proceed from 
the larynx downward to the bronchial tubes ; and in that peculiar 
form of inflammation characterizing the infantile disease called croup, 
the exudation of lymph often extends below the larynx, sometimes 
descending to more or less of the bronchial subdivisions. 

Bronchi. — The portion of the air-passages situated below the 
trachea, and exterior to the lungs, consists of the bronchi. Certain 
anatomical points pertaining to the size and disposition of these tubes, 
possess considerable importance in their supposed relations to dif- 
ferences between the two sides of the chest, in the respiratory sounds 
heard in health and disease, to which reference will be made here- 
after. 

The lower part of the trachea is contained within the chest, passing 
behind the upper bone of the sternum, until it reaches the fourth 
dorsal vertebra, when it bifurcates, forming the right and the left 
bronchus. The right bronchus diverges from the trachea in a direc- 
tion nearly horizontal, forming with the latter almost a right angle. 
Its diameter is about half an inch. It is about an inch in length. 
Its form and anatomical construction is like that of the trachea, 
being composed of from six to eight incomplete cartilaginous rings, 
the posterior portion being membranous and flattened. Before pene- 
trating the lung, which it does at a point equidistant between the 
apex and the base of the organ, it divides into two branches. The 
first or upper division is the smaller, and is connected with the upper 
lobe of the lung. The second, or lower branch, after passing an inch 



48 ANATOMY AND PHYSIOLOGY. 

downward, subdivides into two unequal branches, the small one going 
to the middle, and the larger to the lower lobe. 

The left bronchus is considerably smaller than the right, the diame- 
ter being about three-eighths of an inch. Its length is about two inches, 
being twice as long as the right bronchus. Its direction is obliquely 
downward, forming with the trachea an obtuse angle. It is formed 
precisely like the right bronchus, embracing from nine to twelve 
incomplete cartilaginous rings. It subdivides to enter the lung on a 
level with the fifth dorsal vertebra, about an inch lower than the 
point where the subdivisions of the right bronchus take place. The 
number of branches is two, one for each lobe, the lower being some- 
what longer than the upper. In size or calibre the two bronchi 
united exceed the trachea, as the aggregate of the bronchial ramifi- 
cations within the lungs is greater, in this respect, than that of the 
bronchi ; "so that the velocity of the expired air increases as it ap- 
proaches the exterior."^ 

The bronchi, like the trachea, are surrounded by numerous 
lymphatic glands, called the bronchial glands, and this is the case 
also with the bronchial ramifications within the lungs themselves. 
Enlargement of these glands occurs in bronchitis, in typhoid fever, 
scrofula and tuberculosis, pressing on the bronchial tubes, so as to 
occasion certain acoustic phenomena by modifying the sonorous 
vibrations incident to the current of air during the respiratory acts, 
and even producing obstruction, partial or complete, to the transmis- 
sion of air to the bronchial subdivisions and air-cells. 

The bronchi exterior to the lungs are rarely, if ever, the seat of 
disease not affecting, at the same time, the air-passages, either above 
or below. Foreign bodies introduced through the larynx, however, 
frequently become lodged in this situation, giving rise to more or less 
obstruction, and, if not expelled by acts of coughing, or removed by 
surgical means, not infrequently causing death by suffocation, or from 
the effects of protracted irritation. The statistical researches of 
Prof. Gross, of the University of Louisville, show that foreign bodies 
become lodged much oftener in the right than in the left bronchus. 
This may be attributable, in part, to its larger size, but, in the 
opinion of Prof. Gross, it is mostly due, as was first suggested by 
Mr. Goodall, of Dublin, to the presence of a spur, or ridge, which 
Prof. G. calls the bronchial septum, projecting upward within the 
trachea at the point of its bifurcation. This septum is situated, not 

* Cruveilhier. 



LARYNX. 49 

in the mesial plane, but to the left of it, and therefore serves to direct 
any substance, especially if of considerable size, into the right 
bronchus.^ 

Larynx. — The larynx is much more complex in its anatomical 
construction than the other divisions of the air-passages which have 
been already described. This is owing to the fact that, in addition to 
conducting air to the lungs for respiration, it contains an apparatus 
for the production of the voice. To describe the several parts enter- 
ing into its composition, and their respective offices, would involve 
details needless so far as concerns the general object of this introduc- 
tion. For these the reader is referred to treatises on anatomy and 
physiology. Certain anatomical and physiological points only will 
be noticed which are of special importance in their bearings on the 
study of diseases of the respiratory apparatus, and these will be but 
briefly adverted to. 

The more important of the parts which compose the larynx are 
the thyroid and cricoid cartilages, the epiglottis, and the arytenoid 
cartilages, the latter movable, and provided with several muscles. 
These parts are united by several ligaments, and the internal cavity 
is lined by mucous membrane presenting the same characters as that 
found in the trachea and bronchi. 

The thyroid and cricoid cartilages, with their ligaments, form a 
solid unyielding box, aiFording resistance to pressure both from with- 
out and within its cavity. In this respect it differs from the other 
portions of the air-tube, which may be compressed or dilated by a 
moderate amount of mechanical force. This anatomical point is of 
importance with reference to certain diseases affecting the larynx. 
Taken in connection with the narrowness of a portion of the laryngeal 
canal, the resistance to pressure from within, occasions obstruction, 
and even occlusion, as results of the deposit of certain morbid pro- 
ducts in this situation. It is owing to the circumstances just stated 
that some diseases of the larynx involve serious embarrassment of 
respiration, and frequently end fatally by inducing asphyxia. In- 
stances of this kind are exudative or true croup, acute laryngitis with 
submucous infiltration, and oedema glottidis. 

^ A Practical Treatise on Foreign Bodies in the Air-Passages, by S. D. Gross, M.D., 
etc., etc., 1854. This work contains deductions based on the analysis of a collection of 
nearly fifty cases, embracing, in addition to those coming under the observation of the 
author and his professional friends, all that were to be gathered from medical literature. 

4 



50 ANATOMY AXD PHYSIOLOGY. 

Other points of special importance in their pathological relations 
are presented when the larynx is examined internally. Viewed from 
above downward, the laryngeal canal may be considered as divided 
into three portions, viz. : 1, the superior aperture ; 2, the glottis ; 
3, the inferior space. Of these three portions, the first two are 
chiefly important. We will notice the points pertaining to these 
portions respectively under distinct heads. 

1. Superior Aperture of the Larynx. — This embraces the triangu- 
lar space bounded by the epiglottis in front, the vocal chords below, 
and laterally by mucous folds extending from the summit of the 
arytenoid cartilage to the epiglottis, called the aryteno-epiglottidean 
folds} This portion of the larynx possesses pathological relations of 
great importance. It is in this situation that the submucous effusion 
takes place, constituting the affection known as cedema glottidis. 
The areolar tissue uniting the mucous membrane to the subjacent 
structure, is more loose and extensible here than in other portions 
of the canal. Hence the liability to serous and puruloid submucous 
effusions in this situation, forming tumors which, acting like a ball- 
valve, close the narrow orifice of the glottis with the act of inspira- 
tion, producing obstruction to respiration manifested in the inspira- 
tory act, and, unless relieved by appropriate means, often leading to 
fatal suffocation. The situation of these tumors is such that they are 
generally within reach of the finger, and their existence may there- 
fore be determined by the touch, rendering the diagnosis of cedema 
glottidis positive. This accessibility also renders relief practicable, 
in a large proportion of cases, by resorting to incisions, or scarifica- 
tions with an appropriate surgical instrument, after the method prac- 
tised with signal success in a number of cases by Dr. Gurdon Buck,^ 
of New York : a method of treatment entitled to be ranked among 
the most valuable of the modern improvements of medical practice. 
It is an interesting fact that the loose attachment of the mucous 
membrane at the superior aperture of the larynx which exists in 
adults, does not obtain in children. In them, the membrane is 
closely connected with the parts beneath. Hence, cedema glottidis 
is not a disease affecting children, but occurs only after adidt age. 

' This space is designated, by Prof. Palmer, of the rniversity of Louisville, the otal 
fossa of the larynx. 

* Incorrectly called (Edema glottidis, inasmuch as the edema is situated aboye, not at 
the glottis. 

3 See Transacnona of the American Medical Association, Yols. L and lY. 



LARYNX. 51 

2. Glottis. — The portion of the larynx called the glottis, is that 
bounded by the chordce vocales, or vocal chords. The anatomical 
conformation at this part, and the physiological acts which here take 
place in connection with respiration, as well as phonation, involve 
certain facts, not only interesting, but important in their relations to 
the study of disease. The vocal chords are two in number, on each 
side ; the upper set, formed by folds of the mucous membrane, ex- 
tending from the bases of the arytenoid cartilages to the anterior 
inner surface of the thyroid cartilage ; the lower, containing fibres 
of elastic tissue, extend in the same manner from the arytenoid 
cartilage to the front of the larynx. The upper, or superior vocal 
chords, are also distinguished as the false, and the inferior as the 
true vocal chords. Within the small space between the upper and 
lower vocal chords, on each side, is a depression or cavity called the 
ventricle of the larynx. In this cavity foreign bodies, accidentally 
inhaled into the larynx, sometimes become lodged. By the vocal 
chords the larynx is greatly narrowed at the glottis. Viewed in the 
dead subject, the chords diverge from the point of their junction an- 
teriorly, to their attachment at the arytenoid cartilages, leaving a 
triangular interspace, called the rima or chink of the glottis. This 
fissure is smaller between the lower than the superior vocal chords. 
In an adult male subject, the antero-posterior diameter of the glottis 
is ten or eleven lines ; and the greatest transverse diameter, ^. e. at 
the base of the triangle, from three to four lines, the measurements 
being made at the narrowest part of the glottis, viz., on a level with 
the lower vocal chords. In females, the size of the entire larynx is 
about one-third less than that of the male. At the glottis, in the 
female subject, the antero-posterior diameter is about eight lines, and 
the transverse diameter from two to three lines. Prior to the age of 
puberty, in the male especially, the dimensions of the glottis are less 
than after the remarkable development in the size of the larynx 
which occurs at that epoch. The small size of the aperture of the 
glottis, especially in children, accounts in part for the great danger 
attending the exudation of coagulable lymph in this situation which 
occurs in croup. 

The foregoing description relates to the glottis in the condition in 
which it is observed after death. During life, the condition as 
respects the size and form of the space between the chords, is con- 
stantly varying in consequence of movements connected with the use 
of the voice, and also with the acts of respiration. In speaking and 



52 ANATOMY AND PHYSIOLOGY. 

singing the diversities in the tones of the voice are mainly due to 
different degrees of approximation and tension of the chords, pro- 
duced by the action of muscles attached to the arytenoid cartilages. 
The movements involved in vocalization, according to the recent re- 
searches of M. Claude Bernard,^ are governed by influences trans- 
mitted exclusively through the spinal accessory nerve. Paralysis of 
the arytenoid muscles, so far as they are concerned in phonation, is 
the result of destroying this nerve, the respiratory movements re- 
maining unaffected. Thus, if the nerve be destroyed in a rabbit, the 
breathing continues undisturbed, but the animal is unable to utter 
a cry -when hurt.^ This physiological discovery is interesting, and 
important with reference to the seat and character of nervous 
aphonia. Local affections of the larynx involving the vocal chords, 
occasion modifications of the voice, which thus become important 
diagnostic symptoms. Thus in simple inflammation, or even laryn- 
geal catarrh, as well as in croup, the voice is hoarse and may be 
temporarily lost ; ulceration of the chords from tuberculosis, or 
syphilis, renders it husky and stridulous, and even the abnormal 
dryness incident to epidemic cholera occasions a marked effect, 
amounting sometimes to aphonia. Similar modifications of the sound 
attendant on cough, are also produced by diseases affecting the 
glottis, which thus, in the same way, become diagnostic of a morbid 
condition seated at this division of the air-passages. 

The movements of the vocal chords play an important part in 
respiration. The concurrence of the glottis in certain occasional 
respiratory acts, especially coughing and sneezing, has long been 
known to physiologists ; but that with ordinary respiration an alter- 
nate separation and approximation of the vocal chords take place, 
accompanying the two acts, inspii'ation and expiration, appears to 
have been but very recently ascertained. The interesting and im- 
portant function referred to, giving rise to what are called the 
"respiratory movements of the glottis," is fully established by expe- 
riments made on living animals by Prof. John C. Dalton, Jr., of 
New York, the results of which he has reported for the American 
Journal of Medical Sciences, July, 1854. A dog being completely 
etherized, the common carotid artery on one side tied, and a dissec- 

' Recherches experimentales sur les fonctions du nerf spinal, ou accessoire de Willis. 
par M. Claude Bernard. Paris, 1851. 

2 The writer witnessed this experiment, made by M. Bernard, during the smnmer 
of 1854. 



LARYNX. 53 

tion made so as to bring into view the glottis, there is found to take 
place " during normal respiration, a constant and regular movement 
of the vocal chords, by which the size of the glottis is alternately 
enlarged and diminished, synchronous with the inspiratory and expi- 
ratory movements of the chest." These movements are altogether 
automatic, and continue to go on even after a large opening has been 
made into the trachea, admitting an abundant supply of air by the 
artificial orifice. The size of the rima glottidis when dilated with the 
act of inspiration, may become nearly double that which it has when 
the vocal chords are in a state of rest ; but in this respect there is 
considerable variation with difi"erent respirations, the dilatation being 
more marked when the breathing is hurried or forced, and on the 
other hand, marked contraction taking place when the animal whines 
or cries. 

These variations as respects the approximation of the vocal chords 
with the two respiratory acts, and with difi'erent respirations, pro- 
bably serve to explain, in part, the difi'erences between the sounds of 
inspiration and expiration emanating from within the trachea and 
bronchi, and the variations in the characters of sound which each act 
may present with different respirations, to which reference will be 
hereafter made under the head of Auscultation. 

Abnormal movements of the glottis may become important morbid 
events. Spasm of the muscles approximating the chords occurs as 
an element of inflammation of the larynx, both in croup and simple 
laryngitis. It occurs also as an independent affection in the laryngis- 
mus stridulus of children, and occasionally in adults, interfering with 
inspiration, and occasioning distress in proportion to the degree of 
obstruction from the narrowing of the orifice of the glottis, and, pos- 
sibly, proving fatal. 

The respiratory movements of the glottis are under the control of 
the recurrent or inferior laryngeal nerves. When these nerves are 
divided, the glottis remains immovable, neither dilating nor con- 
tracting. Under these circumstances the column of air entering the 
larynx with inspiration forces the chords together and obstructs the 
orifice, causing death, which takes place more quickly if the animal 
be young. 

3. Inferior Space, — This embraces the short space below the vocal 
chords included within the larynx. In size, form, etc., it resembles 
the trachea into which it merges, and therefore does not claim a sepa- 
rate description. 



54 ANATOMY AND PHYSIOLOGY. 

SECTION II. 

TOPOGRAPHICAL DIVISIONS OF THE CHEST. 

For convenience of reference, especially as regards the results of 
physical exploration, the exterior of the chest is divided into separate 
spaces, technically called regions. These divisions, although wholly 
arbitrary and conventional, are extremely convenient, and the student 
before entering on the study of diseases affecting the respiratory ap- 
paratus, should make himself familiar, not only with their number, 
names, and boundaries, but with their anatomical relations respec- 
tively to the intra-thoracic organs. To these preliminary points this 
section will be devoted. 

In determining these topographical sections, the sole end being 
convenience, simplicity, of course, is to be consulted as much as 
possible. The number of regions should not be needlessly multiplied. 
The boundary lines, to be recollected and readily ascertained, should 
be not entirely artificial, but based, so far as practicable, on natural 
anatomical divisions. And there is an obvious advantage in desig- 
nating them by terms derived from names already assigned to the 
parts which they embrace. 

The first division is into three surfaces, viz., an anterior, a poste- 
rior, and two lateral surfaces. The anterior and posterior surfaces, 
in fact, may be said to be double, each lateral half of the chest being 
considered separately. 

In many instances it suffices to divide these surfaces into a few 
fractional parts, after the plan proposed by M. Louis, and followed 
by other writers. According to this plan, the anterior and posterior 
surfaces are divided into three parts, and designated the upper, 
middle, and lower thirds, of the right or left chest ; and the lateral 
surfaces into two equal parts. This is exceedingly simple, and will 
often answer for reference better than more minute divisions. It is 
important, therefore, to bear in mind the limits of these fractional 
sections. They are as follows : 

Anterior Surface. — The upper third extends from the superior 
extremity of the chest to the lower margin of the second rib. The 
middle third embraces the space between the latter boundary and 



TOPOGRAPHICAL DIVISIONS OF THE CHEST. 55 

the interspace between the fourth and jGifth ribs. The lower- third is 
the portion of the chest below the line just mentioned. 

PoSTEMOE Surface. — The upper third comprises the portion 
above the spinous ridge of the scapula and a line in the same direc- 
tion continued to the spinal column. The middle third is the space 
between the lower boundary of the upper third and a transverse line 
intersecting the inferior angle of the scapula. The lower third is the 
remainder of the chest below the middle third. 

Lateral Surface. — This is divided into two equal portions, 
called the upper, and the lower lateral half of the right, or the left 
side of the chest. 

Not infrequently it is desirable to refer to localities more circum- 
scribed than the foregoing divisions. Hence it becomes necessary to 
subdivide more minutely, into what are more properly termed regions, 
than the fractional sections already mentioned. The regional subdi- 
visions which are generally adopted are the following : 

Anterior Region, a. Post-clavicular, or supra-clavicular. — The 
space above the clavicle, situated over the projecting portion of the 
apex of the lung. h. Clavicular. — The space occupied by the cla- 
vicle, e. Infra-clavicular. — Situated between the clavicle and the 
lower margin of the third rib. d. Mammary. — Bounded above by 
the third, and below by the sixth rib. e. Infra-mammary . — The 
portion of chest below the inferior boundary of the mammary region. 

These regions are, of course, double, i. e. existing on both sides of 
the chest. In addition to these, the portion of the chest anteriorly 
occupied by the sternum is divided into a, the upper, and h, the 
lower sternal region. The two regions just named are separated by 
a line connecting the lower margins of the third ribs. The space 
above the sternal notch, the trachea lying beneath, is called the 
supra-ste7mal region. 

Posterior Region, a. Scapular. — The space occupied by the 
scapula. This space is subdivided into the upper and lower scapular 
regions. The former embraces the portion above, and the latter that 
below the spinous ridge of the scapula, h. Infra-scapular. — The 
space between a line intersecting the lower angle of the scapula, and 
the inferior extremity of the chest, c. Inter- scapular. — The space 
between the posterior margin of the scapula, and the spinal column. 

These regions are double. 

Lateral Region, a. Axillary. — Extending from the highest 
point in the axilla to a transverse line continuous with the lower 



56 AyATOMY AXD PHYSIOLOG-T. 

iKMBdarT of the manmiary region, h. Infra-axiUary. — Extending 
&om tke axillary region to the lower limit of the chest.^ 

The relations of these regions, seTeralljy to the organs contained 
■within the chest, are important to be premised. Supposing the diyi- 
sions to be not confined to the surface, but extended to the centre of 
the chest, what anatomical parts would each section contain ? In 
answering this question, so far as is practicaHy important, we will 
notice the different regions, seriatim, in the following order: 1st, 
those situated anteriorly ; 2d, those situated posteriorly : and Bd, those 
situated laterally. 



I. A^TTEEIOB. REaiOS". 

1. SxiPEA OB. PosT-CLAYTCULAE. — Beneath this region lies but a 
11 portion of Inng, yiz., that part of the apex which projects above 

^e chest, rising a little higher on the right, than on the left side. 
Tke space, howeyer, is of considerable importance in the diagnosis of 
eertain. diseases. The physical signs of tubercle are sometimes early 
manifested in this situation, the tuberculous deposit generally taking 
place first at the apex of the lung. iN^ormally, the surface in this 
region is more or less depressed, forming a concavity. An abnormal 
increase of this depression will be found to constitute one of the 
signs of advanced tuberculosis ; and, on the other hand, the space l5 
abnormally raised, and perhaps becomes bulging, in another affection, 
viz., emphysema. 

2. CLAvicrLAE.. — ^The clavicle extends over the apex of the lung, 
and the remark just made respecting the importance of the post- 
davicular region as a site for the evidences afforded, especially by 
percussion, of incipient tuberculous disease is here equally appKcable. 

3. ts"EEA-CLAYicrxAZ. — This is also an important region with 
reference to the physical signs of tubercle. The signs of all the 
stages of that disease are usually to be sought for in. this region. A 
section carried to the centre of the chest, embracing the Emits of the 
region, would contain an important portion of the upper lobe of the 
limg. The bronchi, after the bifurcation of the trachea, situated 
exterior to the pulmonary substance, are also contained in this sec- 

^ In designating the limits of die dLoerent regions, th.e author has foIlo-wed Walshe. 
The diviaiona and botindaxies, howeTer. are essentially those fboad in other and pxior 
works. 



ANTERIOR REGION. 57 

tion. The bifurcation takes place on a level with the second rib. 
From this point the bronchi on the two sides diverge, pursuing direc- 
tions somewhat different, as already described, the right being 
situated beneath, and the left a little below the costal cartilage of 
the second rib. The presence of the bronchi gives rise to certain 
modifications of the sound produced by respiration, in health, as well 
as disease, which are to be studied in this region; and owing to 
anatomical differences in the bronchi of the two sides, which have 
been noticed in Section First, it will be seen hereafter that a natural 
disparity exists as respects these modifications of respiratory sound. 
Normally the infra-clavicular region is in most persons slightly 
convex, different persons differing considerably in this particular. 
This convexity abnormally increased becomes a sign of emphysema, 
and an abnormal depression or flattening in this situation frequently 
attends tuberculosis of the lungs. 

4. Mammary. — Some important points pertaining to the anatomy 
of the intra-thoracic organs, have relation to the space occupied by 
this region. As respects the organs lying beneath, the two sides 
differ. A considerable portion of the heart is situated in the left 
side within its limits, viz., the left ventricle, and auricle, and a por- 
tion of the right ventricle. The site of the heart is often distin- 
guished as a separate region, called the cardiac, or prsecordia. Over 
a triangular space extending from the sternum into the left mammary 
region, the heart is in contact with the walls of the chest. This 
triangle lies between the fourth and sixth ribs. The limits of the 
heart beyond this space are to be taken into account in physical 
exploration. They extend vertically from the upper to the lower 
boundary of the left mammary region, i. e. from the third to the 
sixth ribs, and transversely in the line of the fourth rib nearly to the 
nipple. The presence of the heart, as will be seen hereafter, occa- 
sions important modifications of the phenomena determined by 
percussion and auscultation, and disturbs that equality between the 
right and left mammary regions, as respects the physical signs inci- 
dent to health, which generally characterizes corresponding localities 
on the two sides. The disparity just referred to is of practical 
importance in its bearing on physical diagnosis. Appreciating its 
degree and extent prevents attributing to changes produced by 
disease, phenomena which are entirely normal ; and, on the other 
hand, a morbid condition may occasion a notable diminution in the 
normal disparity. The latter obtains in cases of emphysema, in 



m AlfATDMT A2nD PHTEIDIiDGX. 

■wMcli tlie OYer-distended lung covers the Leart entirelT, or cro-wdinr 
it from its natural sitnation occnpies its place in tlie prsBCordia. Th- 
impnlse prodnced l)ythe JStrTkrng of the heart's apex ar-: ;_ _- 
■walls of the chest falls within the left manunary region.. 

I^ormally this impTilse is seen and felt hetween the fifth and sktL 
ribs, about midvay between a Yertical line passing thrBi^k 
nipple, and another coincident with the left margin of the 
The position of this point of apex impulse is important in cmmeritSor 
with diseases affecting the respiratory apparatus as well as the heart. 
In certain pnlmonary affections the heart is displaced. It is carried 
in some cases of chronic plenrisy to the right of the Btemum, ajid thf 
impulse may be felt in the right mammary, or infra-daTiciilar region 
This transference of the heart's inrpnlse to other situations, thus bf-- 
comes an important diagnostic sign of pulmonary disease. jLiseMje 
of the impulse in the normal position, without its being ap|iiT ! iflJH fe 
elsewhere, may ako be a Taluable sign of pulmonary disease. 

The lines corresponding to the fissures diridnig anteriorly the 
lobes of the lungs fall within the mammary regions. The relations 
of these lines to the exterior of the chest are important to be borne 
in mind. On the left side the interlobar fissure commences at h 
point a little below the nipple, between the fourth and fifth ribs, an: 
from this point it runs ohliquely upward ajid outward to the axillary 
region. On the right side the fissure diyiding the upper and to 
lobes commences at the fourth costal cartilage, and pmrsues a c: 
obliquely upward and outward for a distance, varying in diEf 
persons. The fissure between the middle and lower lobes commencet 
a short distance below, and extends in a prmilarr drrectiDn. T5ie 
portion of the lower lobe situated anteriorly below the middle lobe. 
is quite small, as has been already seen, and sometimes the wi r 
of this lobe is contained in the lateral and posterior regions of zhi 
chest. 

A small part of the heart is CDntained beneath the right mamn^Lr- 
region, viz., portions of the right auricle and ventricle. 

On the right side, the convexity of the diaphragm rises into the 
mammary region as high as the fourth rib. On the left side, the point 
to which it extends is a little lower. This fact accounts for certcii 
modifications of phenomena developed by physical exploration. 

The presence of the mammary gland in the female, and in some 
instances a large development of the pectoral muscle in the male, are 
found to interfere, to a greater or less extent, with physical explora- 
tion in this region. 



ANTERIOR REGION. 59 

5. Infra-mammary. — This region, like the preceding, has rela- 
tions, on the two sides, to different organs. On the right side, 
extending upward, nearly or quite to the superior boundary, is the 
liver, covered with the diaphragm. The phenomena determined by 
physical exploration in health, are quite different from those in other 
regions including pulmonary substance. These phenomena are some- 
times attributed to disease by those who overlook the fact that, owing 
to the presence of the liver, they are normal in this situation. On 
the left side, this region embraces portions of the stomach, spleen, 
and left lobe of the liver, but the relative proportion of the different 
parts lying within the limits of the region varies considerably in dif- 
ferent individuals, and still more at different times in the same person. 
This is owing to the fact that the size of the three organs mentioned 
is far from uniform in health, and this is true more especially of the 
stomach. Greater or less distension of the stomach with gas, oc- 
casions marked diversities in the phenomena determined by physical 
exploration of the left infra-mammary region. Enlargement and 
atrophy of the liver and spleen, also occasion modifications of these 
phenomena. 

In this region, the intercostal depressions, if visible anywhere, are 
usually more or less marked. The signs of disease which pertain to 
these depressions are, therefore, to be sought for in this portion of 
the chest. The evidences of the presence of liquid effusion within 
the pleural sac, are presented especially in the infra-mammary 
region. 

6. Supra-sternal. — No portion of the substance of the lungs lies 
beneath the small space occupied by this region, but the whole of 
the space is filled by the trachea. In this space, examination is 
made in studying the phenomena of respiration developed within the 
trachea. 

7. Upper Sternal. — Beneath the upper portion of the sternum, 
at the centre of a line connecting the second ribs, the bifurcation of 
the trachea takes place. Below this point, the lungs on the two 
sides are nearly in contact at the mesial line, covering the primary 
bronchial divisions. 

8. Lower Sternal. — This part of the sternum covers a portion 
of the heart, viz., a large share of the right, and a little of the left 
ventricle. The liver encroaches somewhat on this region, and also 
the stomach when distended. Situated above the heart, a small 
portion of the left lung is contained within its limits, and to the 
right of the mesial line a larger portion of the lung on that side. 



60 ANATOMY AND PHYSIOLOGY. 



II. Posterior Kegion. 

1. Scapular. — The scapula is situated over ^he superior and pos- 
terior portion of the upper pulmonary lobe, covering also a portion 
of the upper part of the lower lobe, no other important parts lying 
beneath it. This region is subdivided into the upper and lower sca- 
pular ; the former situated above, and the latter below the spinous 
ridge. 

At the upper part of the lower scapular region, terminates the 
fissure separating the upper and lower lobes of the lungs. From this 
point of termination, the interlobar fissure pursues an oblique direction 
downward, passing through the lower axillary and mammary regions 
to the fifth interspace on the right side, and to the space between the 
fourth and fifth ribs on the left side. A diagonal line drawn be- 
tween the two points just mentioned, will mark the situation of the 
division between the lobes, a matter of interest and importance in the 
diagnosis of lobar pneumonitis, or inflammation of the substance of 
the lungs extending over a lobe. 

2. Infra-scapular. — Pulmonary substance occupies the space 
within the chest corresponding to this region, on the right side above 
a transverse line drawn from the eleventh rib. The liver rises to 
this line. On the left side the lower part of the region contains 
a portion of the spleen. 

The lower lobe on the left, and the lower and middle lobes on the 
right side, fill the whole of this region above the diaphragm, and also 
a portion of the scapular region. In cases of inflammation afi'ecting 
(as is usual) the lower lobe in the adult (lobar pneumonitis) the 
physical evidences of disease are here presented, and are to be 
sought for posteriorly, not in front, a small portion only of the lower 
lobe, as already stated, extending to the anterior part of the chest. 

3. Inter-scapular Region. — In addition to the substance of the 
lungs on both sides, the trachea descends into this region, and bifur- 
cates. The point of bifurcation, as already stated, is at the fourth 
dorsal vertebra. From this point the two primary bronchi diverge, 
running across the region obliquely downward and outward, the 
direction on the two sides being somewhat difierent, as described in 
Section I. It is in this region behind, and in the infra-clavicular 
region near the sternum, in front, that examinations are made for the 



LATERAL REGION. 61 

respiratory sounds developed within the primary bronchi, a matter 
of interest and importance, as will be seen hereafter. 

The topographical divisions of the chest have been described in 
this section, and the relations of the several regions to the organs 
lying beneath, stated briefly, but comprehensively enough to prepare 
the student to enter on the study of physical exploration. The 
details that have been presented are in themselves dry and uninte- 
resting ; nevertheless, they should not only be read and compre- 
hended, but dwelt upon until they become perfectly familiar, as a 
preparatory step to the subjects which are to follow. In order 
to obtain a clearer knowledge of the regions, and that the mind may 
become so familiarized with them as to refer to them, and their 
important anatomical relations, with readiness, it will be found to 
be a useful exercise to practise mapping them out either on the 
patient or on the dead. By marking with India-ink or black paint 
the boundary lines of the different divisions, their situations, etc., will 
very soon become firmly impressed on the memory, and much more 
satisfactorily and usefully illustrated, than by means of pictures or 
diagrams. 

III. Lateral Region. 

1. Axillary. — A section corresponding to the boundaries of this 
region would contain a portion of the upper lobe of the lungs, with 
large bronchial tubes. 

2. Infra-axillary. — A section here would embrace, in addition 
to lung substance on both sides, a portion of the spleen and stomach 
on the left side, and on the right side the upper part of the liver. 



PAET I. 

PHYSICAL EXPLORATION OF THE CHEST. 



PART I. 

PHYSICAL EXPLORATION OF THE CHEST. 



CHAPTER I. 

DEFINITIONS— DIFFERENT METHODS OF EXPLORATION- 
GENERAL REMARKS. 

Physical exploration of the chest is the examination of this region 
by means of certain methods involving principles of physical science, 
with a view to determine the existence or non-existence, the nature 
and the situation, of intra-thoracic disease. Limiting attention to 
the respiratory organs, various changes in their physical conditions 
are incident to the different diseases to which they are liable. 
Among these changes, the study of which belongs to morbid ana- 
tomy, are increased and diminished density of the pulmonary organs; 
loss of substance, leaving cavities; dilatation or contraction of the 
air-tubes ; reduction in volume and displacement from the presence 
of liquid in the serous-sacs, etc. Owing to the conformation of the 
chest, the elasticity of its walls, and the movements which they un- 
dergo, in connection with the peculiarities in structure of the con- 
tained organs, air being constantly present, and in motion to and fro 
with the acts of respiration, the changes just referred to give rise to 
certain phenomena appreciable by the senses, and these phenomena 
are distinguished as the pliysical signs of disease. The discrimina- 
tion of diseases, so far as these signs are concerned, constitutes phy- 
sical diagnosis. 

The following are the different methods of physical exploration : 
1. Striking the chest with the finger, or an artificial instrument, in 
order to determine any deviations from the sounds which are elicited 
by this process in a condition of health. This method is called per- 
cussion. 



m 



PHYSICAL EXPI/OBATI 



:i IZE CHEST. 



% Xasiteiiiig, wkk iiiie ear applied directly to the ehest, or tlnoiLg: 
a. condnctiiig iiisitmmenf^ to diseoTer morlnd eonnds produced by tlr 
moTemcnls of the air in r^piralio% or by the acts of speaking an '.. 
coa^ang. This method is called aMtemUMism^ 

3. TJ^gawiraing fhc chfist inth theeye, to see if there are any changes 
in form or symmetry, and if the Ti^le motioBS are natoraL This 
i_ _ c^ed imspeetunu 

- ._ 7^? the hand to tlie ch^t, to aseertain whether any ab- 
1 : z^ . - ?iK are appreciable by tondi, dne to the moTcments of 

: r r -.: : . . : re espedally the act of peaking. TMs method is 



Co_.T 



or gradna: 



air are cor: 
of disease. 

The Dtf-i 



nary 



two la^ 
to be 



seoon: 
nient 

ioatts 
witb ■■: 

c: - 



'?t, or parts of the chest, by means of a tape, 
btain accurate informalion of alterations 
_ zif tuod is called meiiguraii0ii. 

\ : p^ SQnnds produced when liquid and 

. - . - _ '_ :>ecnrs, occasionally, as the restilt 

: ^ . _ T six methods of esaminatioii jnst 

EiguM^ in distinction &om the ordi- 

:. ' - L T ' i : : T r are sometimeB styled rational^ 

" i: ^ Z^iji of these epitbets, as con- 

5 1 certain significance. But the 

T :ir_ :Lt zrst, vMch implks an error, 

-_r ~:: = : f and s^mptom*^ are often 

:. T :.T z:^: :; y:. :e the j^Ti^ucal and the 

1 1 : :_ 7 :: ; : : disease. It is conve- 

^^r ::_ ^r :t.i::, :l: :l.uie can be no ohjection 

. ::::::. 7 : t _; t it : zientioned, in conformity 



7 T-" 7 :::,llj inTolved in the practice 

"-_:.:. -reats of the phenomena an: 

J-i. : knowledge of physical 

: -^ _ 7 ~!"h aconstic principles 

~ _ - ; _ ;._:•- 7 ~ 7 :y one is familiar. 

rrne that :_7 -: ' " : acoustics will 

rstand more fniij and to investigate 

ised on the facts of that science., this! 

. 7 end and apply, sufficiently for all 



gnorant of the subject, that 



DEFINITIONS. 67 

the signs generally represent uniform and definite morbid conditions ; 
in other words, that each sign possesses its own special significance ; 
and, therefore, for the practice of physical exploration, that it is simply 
necessary to be able to recognize and appreciate certain abnormal 
sounds. According to this view, physical exploration is merely a 
mechanical art. This is implied when symptoms, as distinguished 
from signs, are called rational. The inference is, that to determine 
the value of signs, processes of reasoning are not required : that they 
express in themselves their full import, and that the ability to discri- 
minate difi*erent diseases thereby depends mainly on manual tact and 
the cultivation of the senses. The student should, as soon as possi- 
ble, dispossess the mind of this error. Few signs, individually, are 
pathognomonic. Their diagnostic signification depends on their com- 
bination with other signs, and on their connection with symptoms. 
Hence, something more than delicacy of hearing and skilful mani- 
pulation is requisite. Thought and the exercise of judgment are 
needed, not less than in determining the nature and seat of diseases 
by their vital phenomena. In short, physical exploration developes 
a series of facts which are to be made the subjects of ratiocination in 
their applications to diagnosis, as much as facts obtained by other 
methods. 

To be convinced of the great benefit which practical medicine has 
derived from the introduction of physical methods of exploration, it 
is only necessary to contrast the facility of discriminating the most 
common pulmonary affections at the present time, with the difficulty 
which confessedly existed prior to the employment of these methods. 
If the reader will turn to the works of Cullen, or the more recent 
writings of Good, he will find that these authors acknowledge the in- 
ability of the practitioner often to distinguish, by means of symptoms, 
pneumonitis, pleuritis, and bronchitis from each other, so that for 
practical purposes it was deemed sufficient to consider these three 
affections as one disease. At the present time, with the aid of signs, 
it is very rarely the case that the discrimination cannot be made 
easily. And that this improvement is mainly due to physical 
exploration, is shown by the fact, that to distinguish these afi*ec- 
tions by means of symptoms alone, is still nearly as difficult as 
heretofore. But to realize the importance of the subject it is not 
necessary to institute a comparison of the present with the past. It 
is sufficient to refer to the mistakes in diagnosis daily made by prac- 
titioners who rely exclusively on symptoms, which might be easily 



68 PHYSICAL EXPLORATIO^' OF THE CHEST. 

avoided by resorting to physical signs. It may not be amiss to cite 
some illTistrations from instances that hare fallen under my own 
observation. Examples of confounding tbe three affections just 
named are sufficiently common. Of these affections, pneumonitis and 
pleui'itis are not unfrequently latent, so far as distinctive vital phe- 
nomena are concerned, and consequently are overlooked. Chronic 
pleurisy is habitually mistaken for other affections by those who do 
not employ physical exploration. Of a considerable number of cases, 
the histories of which I have collected, in a large proportion the 
nature and seat of the disease had not been ascertained.^ Yet nothing 
is more simple than to determine the existence of this affection by an 
exploration of the chest. Acute pleuritis and pneumonitis are some- 
times completely masked by the symptoms of other associated affec- 
tions, and thus escape detection. This is observed in fevers, and 
when head symptoms become developed, especially in childi-en. ITnder 
these cii'cumstances, the practitioner who avails himself of physical 
signs is alone able to arrive at a positive conclusion as to their exist- 
ence. Emphysema is an affection which cannot be recognized by 
symptoms alone, and hence, they who neglect signs have no practical 
knowledge of it. Acute tuberculosis I have known repeatedly to be 
called typhoid fever ; on the other hand, I could adduce numerous 
examples of different affections erroneously considered to be phthisis, 
and a still greater number of instances in which patients with this 
affection were incorrectly supposed to be affected with some other 
disease than tuberculosis. Were we to dwell upon these, and other 
mistakes which might be added, it would be easy to show that they 
are unfoiinmate, not merely in a scientific point of view, but with 
reference to practical consequences involving the welfare, and it may 
be the lives of patients. 

The physical exploration of the chest has certain striking advantages 
which may be briefly noticed. The phenomena thus developed are 
entirely ohjeetive. They have no connection with the mind of the 
patient. They are therefore free from the difliculties and liabilities 
to error arising from ignorance, deception, self delusion, disposition 
to exaggeration, or desii-e of concealment, which belong to subjective 
symptoms. They are available in children too young to give infor- 
mation respecting their diseases ; in cases of mental derangement, and i 
in the condition of coma. The evidence which they afford of morbid | 
conditions is more positive than that furnished by symptoms. Fre- 

' Tide. Clinical Report on Chronic Pleurisy, bv the author. 



GENERAL REMARKS. 69 

quently in attempting to arrive at a diagnosis by means of the latter, 
we can only reach an approximation to certainty. In forming con- 
clusions we are obliged to balance probabilities. This uncertainty, 
of course, influences the management of disease. But the informa- 
tion obtained by the aid of signs is often so complete and precise, as 
to leave nothing more to be desired. The proof of the existence of 
certain affections is exact and demonstrative, leaving no room for 
hesitation. Physical signs are more readily and quickly available 
than symptoms. Diagnosis is thus more prompt, as well as more 
positive. Hence diseases are recognized at an earlier period, a point 
often of very great consequence as regards successful treatment. 
Their value is frequently as conspicuous negatively as positively ; 
that is, deductions from their absence are as important and decisive 
as from their presence. Finally, in view of the considerations just 
presented, this branch of practical medicine affords to the practitioner 
a sense of gratification greater than that which he derives from clini- 
cal investigations by means of symptoms. 

By thus directing attention to some of the points of contrast be- 
tween symptoms and signs, it is not to be concluded that these two 
classes of phenomena hold conflicting relations in the practice of 
medicine. Neither is to be employed in diagnosis to the exclu- 
sion of the other. They are not to be disconnected save for abstract 
consideration. They are always to be brought to bear conjointly in 
clinical investigations ; combined, they lead to conclusions which 
neither may be competent to establish alone. They mutually serve 
to correct or confirm deductions drawn from either separately. 
It is never to be lost sight of in the study or practice of physical 
exploration, that to devote too exclusive attention to signs, is as 
much a, fault as to ignore their value, and rely entirely on symptoms. 

Notwithstanding these advantages, and the importance of physical 
exploration in the diagnosis of diseases affecting the respiratory appa- 
ratus, it is employed by only a small proportion of medical practi- 
tioners. Some even now profess to attach but little value to signs ; 
a much larger number practically repudiate them. This fact, how- 
ever, may be stated, viz., no one who has devoted sufficient attention 
to the subject to apply successfully the well-established rules of phy- 
sical diagnosis at the bedside, has ever denied having received great 
assistance therefrom, or advocated a neglect of them. They who de- 
preciate and forego the benefits of physical methods of examination, 
have had little or no experience of their practical application. If 



70 PHYSICAL EXPLORATION OF THE CHEST. 

the foregoing assertion be true, the explanation of the fact that this 
branch of practical medicine is properly estimated and cultivated by 
so few, is to be sought for in causes discouraging the pursuit, or in 
difficulties attending it which are not easily surmounted. Such causes 
and apparent difficulties exist. It is a common impression that it is 
useless to attempt to accomplish anything satisfactory in physical 
exploration unless the sense of hearing be singularly apt to distin- 
guish nice shades of difference in sounds ; and in addition to this, 
extraordinary application and opportunities are supposed to be indis- 
pensable. The pursuit is generally regarded as extremely compli- 
cated, requiring an experienced teacher and a large hospital, to be 
prosecuted with success. These ideas do great injustice to the sub- 
ject. So far as the more important diagnostic principles are con- 
cerned, both in their apprehension and application, they are exceed- 
ingly simple. The points which are abstruse or intricate, as a general 
remark, are those which are of the least practical consequence. Oral 
instruction by an expert, with explanations and illustrations at the 
bedside, are undoubtedly of very great use, as well as the selection of 
cases which a large hospital affords. But I venture to assert with 
positiveness, that these advantages, although desirable, are not essen- 
tial ; and that an intelligent student or practitioner, solely with the 
aid of books, and with opportunities for observation which may be 
enjoyed in every village, may, by means of a very moderate amount 
of exertion, acquire a practical knowledge of physical signs sufficient 
for ordinary purposes of diagnosis.^ 

A tithe of the time so often occupied by medical students in becom- 
ing very indifferent performers on some musical instrument, would 
more than answer to make them adepts in the practice of physical 
exploration. Acuteness of the sense of hearing, and an ear for music, 
are doubtless useful qualifications ; but the sounds to be recognized 
and distinguished from each other, are generally easily discriminated, 
and I have known tolerably good auscultators who were not only 
unable to appreciate musical notes, but who labored under some 
degree of deafness. 

In treating of physical signs, they are to be considered under two 

' I would not be understood, by these remarks, to undervalue the importance of a 
master's instruction ; but for the encouragement of those who may not be able to avail 
themselves of this advantage, in connection with hospital opportunities, I desire to express 
the conviction that, without them, a proficiency sufficient for discrimination, in a large 
proportion of the cases occurring in medical practice, is attainable. 



GENERAL REMARKS. 71 

aspects. The first and more important is the significance and value 
■which belong to them separately and in combination. What are the 
abnormal conditions which they represent? This question covers 
all that pertains to the practice of physical diagnosis. In a practical 
treatise, therefore, the facts embraced in this view of the subject 
are of paramount importance. How are these facts ascertained ? in 
other words, in what manner is our knowledge of signs, as the re- 
presentatives of morbid changes, obtained ? Physical phenomena 
become signs of disease whenever it is established that there exists 
a constancy of association of these phenomena with the physical 
alterations which disease induces. Being uniformly found together, 
a connection between the two is logically proved, so that the for- 
mer may be regarded as the indices of the latter. This is the 
basis of the science of physical exploration. And this constancy of 
association is determined by clinical observations together with the 
information derived from post-mortem examinations. Certain sen- 
sible phenomena observed during life are found uniformly present 
in cases in which dissection reveals certain morbid changes. Hence, 
whenever particular phenomena are recognized, we are authorized to 
infer the existence of corresponding morbid conditions ; the phenomena 
in this way become signs, and, conversely, whenever certain morbid 
conditions are ascertained to exist prior to death, we look for the 
physical phenomena, or signs, which previous observations have shown 
to coexist with them. In short, the evidence of the value and signifi- 
cance of signs rests on experience. This is a fact not to be lost sight of 
in the study of physical diagnosis, and especially in the endeavor to 
contribute additions to our knowledge of the subject. Much as has 
been already accomplished, there is ample scope for further researches 
in this direction. Many questions of practical interest and impor- 
tance are open for investigation by means of the analysis of recorded 
observation in the living and dead subject. The application of the 
numerical method to the study of physical signs, so far from having 
been completed, has hardly been as yet commenced. Much is to be 
expected from this source which will give greater precision to our 
knowledge, as well as enlarge its boundaries. Another point pertain- 
ing to the cultivation of this pursuit, the importance of which does 
not appear to have been sufficiently appreciated, may be here noticed. 
I refer to careful and systematic explorations of the healthy chest. 
The results of such examinations constitute, of course, the point 
of departure for determining the phenomena of disease. In this way 



72 PHYSICAL EXPLORATION OF THE CHEST. 

only are to be ascertained variations from the phenomena usually 
observed, which are liable to take place irrespective of disease, i. e. 
within the limits of health. In subsequent chapters will be adduced 
results obtained by an analysis of a series of explorations made in 
subjects presumed to be entirely healthy, the phenomena being 
recorded at the moment of observation. These researches might be 
extended with advantage. Our knowledge of healthy physical signs 
is not yet complete, and in proportion as*it is defective are we liable 
to error in judging of the signs of disease. 

A second aspect under which physical signs are to be considered 
is the mechanism of their production. This is the theoretical part of 
the subject, and is to be pursued with great circumspection. The 
endeavor to account for the results of physical exploration opens a 
wide range for speculation. A priori conclusions as to the phenomena 
which ought to accompany certain physical changes, are not admissible 
except as temporary hypotheses to be tested by the results of clinical 
and post-mortem observations. Experiments made on the dead subject, 
and merely artificial contrivances, in order to imitate the sounds which 
characterize certain signs, or to prove the correctness of certain hypo- 
thetical explanations, are to be received with a certain amount of dis- 
trust, for it is almost impossible to ascertain and reproduce all the phy- 
sical elements which are combined in the living body. There is reason 
to believe that this attempt has given rise to false views, to which re- 
ference will be made hereafter. Desirable as it undoubtedly is to 
understand as fully as possible the rationale of physical signs, their 
importance and availability in diagnosis by no means depend on the 
attainment of this end. Several of the signs will afford illustrations 
of the truth of this remark ; its correctness, indeed, is implied in the 
fact abeady stated, viz., that our positive knowledge of the significance 
and value of signs is based on experience. 

In entering on the study of physical exploration the first object 
should be to become acquainted with the ascertained facts and 
general principles pertaining to the subject. It is sometimes advised 
that the student should at once commence clinical observations with- 
out any previous acquaintance with the signs which characterize 
■ (Esease. This is to place him in the position of the original explorers, 
without, it may be presumed in most instances, their genius and 
.indu£try ! Progress in this way must be slow, and unsatisfactory, 
compared with that which may be made by availing oneself at the 
outset <fif the labors of others. Certain practical points have been 



GENERAL EE MARKS. 73 

established. These are to be understood by resorting to oral instruc- 
tion or books, and as fast as practicable they are to be verified by 
actual observation. The latter is rendered less difficult by the 
fact, as will be seen hereafter, that a large share of the signs of 
disease are exemplified in the living healthy subject. The signs 
developed by the difi'erent methods of exploration are to be studied 
singly and combined. Isolated from the others, the knowledge per- 
taining to each has relation to its sensible characters, the manner in 
which it is developed, its significance and diagnostic value, and the 
probable explanation of the mode of its production. It is, however, 
as already intimated, very rarely the case that the diagnosis rests on a 
single sign. Various signs are generally associated, and it is by 
their combination that we are enabled to arrive at positive conclu- 
sions as to the nature, seat, or stage of diseases. Were it necessary 
to rely exclusively on the special significance of individual signs, the 
application of the results of physical exploration to diagnosis would 
be much more limited than it is. By uniting the information derived 
from the difi'erent methods of examination, its scope is greatly en- 
larged. Moreover, in determining the existence of individual signs, 
our observations are rendered positive, or otherwise, by reference to 
their combinations. The mutual relations, therefore, of the difi'erent 
signs constitute a highly important branch of the subject. Separately, 
the signs may be compared to the words which compose a language ; 
the laws of their combinations are analogous to syntax. A know- 
ledge of both is necessary in order to interpret correctly the physical 
expression of disease. 

For the successful practice of physical exploration the facts and 
principles pertaining thereto must not only be understood, but they 
must be at command, so as to be readily available. The practitioner 
must be qualified to appreciate characteristic sounds, and determine 
the value of their combinations, without waiting to refer to authori- 
ties, or even for deliberate meditation. The signs must be made 
as familiar as household words. This is to be attained by practice, 
and preserved by constant exercise. Every one accustomed to prac- 
tise physical exploration, must have noticed that after an inter- 
mission in its employment for some time, the usual facility and quick- 
ness in arriving at satisfactory results is temporarily somewhat im- 
paired. For this reason, were there none other, the habit of daily 
examining the chest, to a greater or less extent, in all cases, is to be 
recommended. 



74 PHYSICAL EXPLORATION OF THE CHEST. 

In treating of the principles and practice of physical exploration 
in the following pages, the aim will be to present facts and conside- 
rations tvhich have direct practical bearings on diagnosis. Inquiries 
purely theoretical or relating remotely to the discrimination of dis- 
eases, and discussions of mooted points, will receive but little atten- 
tion. Such inquiries and discussions, for the most part, have refe- 
rence to the mechanism by which the phenomena detected by the 
diifferent methods of exploration are produced. To this department of 
the subject I shall devote, relatis'ely, but a small space, in part from a 
conviction that the advantage of the reader will thereby be consulted, 
and it is but candor to add, also, because my own studies have been 
chiefly confined to clinical observations. 



CHAPTER II. 

PEECUSSION. 

Exploration by percussion consists in striking the chest so as to 
induce sonorous vibrations. In consequence of the elasticity of the 
thoracic walls, and the presence of air in the pulmonary cells, a certain 
degree and kind of sonorousness is produced when strokes are made in 
a manner to elicit sound ; and various changes in these physical con- 
ditions incident to disease, occasion corresponding deviations from the 
type of sonorousness pertaining to a healthy state. Percussion may 
be practised in different modes. As first introduced by Auenbrugger, 
in 1761, the blows were applied directly to the chest, without any 
intervening medium. This is called immediate percussion. For 
obvious reasons this mode is objectionable, and is now nearly obsolete. 
Shortly after the more recent discoveries by Laennec, which served 
at once vastly to enhance the importance of the method of explora- 
tion under present consideration, mediate percussion, as it is termed, 
was employed by M. Piorry, of Paris, and has since been generally 
adopted. In mediate percussion the blows are made on an intervening 
solid medium, applied to the chest, and styled Sipleximeter. The plexi- 
meter used by Piorry is a thin oval disk of polished ivory, about 
two inches in length, and an inch in its greatest width, with an up- 
right border at both extremities projecting about half an inch. These 
projections serve as handles by which the instrument is adjusted, and 
held in contact with the thoracic walls. On one side a scale for 
measurement is sometimes marked in black lines, which is often useful 
in determining accurately spaces and distances on the chest. Piorry's 
pleximeter is generally employed in the Parisian hospitals, and to a 
considerable extent in other countries than France. Other substances 
have been recommended. A square block of caoutchouc forms a con- 
venient pleximeter, and is preferred by M. Louis and some others. 
A circular piece of sole leather, li inches in diameter, fixed in a steel 
stirrup, so as to be movable on a point connecting the extremities of the 



76 PHYSICAL EXPLORATION OF THE CHEST. 

Stirrup ; a handle, constructed of wood and steel, attached to the head 
of the stirrup, the whole eight inches long, devised by Dr. I. Burne, 
of Ireland, I have found to answer the purpose satisfactorily. Many, 
however, if not the majority of practitioners who practise physical ex- 
ploration, use, for the most part, simply the first or second finger of the 
left hand, the palmar surface being generally applied, in a transverse 
direction to the chest. The finger, as a pleximeter, is superior, in 
many respects, to any artificial instrument. In size and form it is 
well adapted to be applied over the ribs, and in the intercostal spaces. 
The force with which it is applied can be easily graduated. It renders 
the operation of percussion less formidable to the patient, and in 
cases of children especially, this is not a small advantage. It afi'ords 
information as respects the sense of resistance, which it will be seen 
presently is a point of considerable importance. Finally, among 
minor recommendations, it costs nothing, and in the most literal sense 
is always at hand ! The only disadvantage attending it is the liability 
to sufi'er injury if in constant use. This I have found, at times, a 
serious impediment. The dorsal surface is apt to become tender, 
swollen, and in fact, inflamed from the repeated blows, continued daily, 
especially when forcible percussion is practised with a view to clinical 
illustrations. Other pleximeters than the finger obviate the difficulty 
just mentioned, but aside from this advantage it may be doubted if, 
for ordinary purposes, there are any reasons why they may not be 
dispensed with, at least in private practice. In hospital or dispensary 
practice, owing to the number of patients to be examined, an artificial 
instrument may be requisite. 

Percussion may be made by one or more of the fingers of the right 
hand, or with some kind of hammer constructed for that purpose. 
The latter is termed a percussor. A variety of instruments for 
making percussion have been contrived. It will suffice to mention 
some of them, without entering into minute descriptions. 

A German practitioner. Dr. Winterlich, employs a small steel ham- 
mer, into which is inserted a piece of caoutchouc, the latter being 
brought into contact with the pleximeter in making the strokes. Dr. 
I. Hughes Bennett, of Edinburgh, gives to this instrument a decided 
preference over the fingers. A similar instrument accompanies the 
pleximeter of Dr. Burne, save that, instead of caoutchouc, a cone of 
leather is inserted into the head. Professor Trousseau, of Paris, 
makes use of a slender rod of whalebone, to the extremity of which 
is fixed a conical piece of caoutchouc. In Dublin, a stethoscope with 



PERCUSSION. 7T 

an India-rubber rim surrounding the ear-piece is employed as a per- 
cussor. This originated with Dr. Marsh. Professor Bigelow, of 
Boston, recommends a ball of worsted, covered with velvet, to which 
a handle is attached. Most practitioners, however, are satisfied with 
one or more of the fingers of the right hand, bent iti a half circle ; 
which certainly, in most instances, answers all practical purposes. 

The mode of performing percussion is a point of practical impor- 
tance. It is not at once an easy matter to strike so as to produce in 
the most satisfactory manner sonorous vibrations. Certain rules are 
to be observed, and success depends on a tact to be perfected by 
practice. The fingers are to be flexed so that their ends shall fall 
perpendicularly on the pleximeter. The strokes are not to be made 
with the pulpy portion of their extremities. The blows should be 
given with a certain quickness, the fingers brought into contact with 
the pleximeter and withdrawn as it were instantaneously, by a move- 
ment limited almost entirely to the wrist joint. When a light per- 
cussion is desired, the index or middle finger alone may be employed, 
but when greater force is requisite, two or three fingers should be 
used conjointly. In the latter case, it is generally recommended to bring 
the three fingers together as compactly as possible, and support them 
with the thumb. I find it better to arrange the fingers on a line and 
percuss without bringing forward the thumb into apposition. With 
the thumb free, the movements at the wrist are unrestrained, and the 
fingers do not need any additional support. The type of perfect 
percussion is witnessed in musical performances, on a series of bells 
representing the diJBferent notes of the gamut. It is also seen in the 
manner in which the little hammers strike, and rebound from the 
strings of a piano-forte when the keys are touched. The object in 
these examples is precisely the same as in percussing the chest, viz., 
to elicit sounds as distinct and pure as possible, and they may 
therefore be taken as models for imitation. It is generally easy to 
know at a glance, by the mode in which percussion is made, whether 
it is resorted to in order to develope physical signs with the import of 
which the practitioner is practically familiar, or whether it be em- 
ployed merely for form's sake, or to afi*ect an acquaintance with the 
subject. Rules of manipulation pertaining to the practice of per- 
cussion, in addition to the foregoing, will be given presently. 

A mode of practising percussion, involving, for certain purposes, 
an important improvement, was proposed some time since, by Dr. 



1^ 



PHYSICAL EXPLOKATION OF In 



Gr. P. Camnuum,* and Prof. A. Clark, of Me~ 7 1 The pe: : li- 
ritj of tills mode consists m combining ^'r.\i :: Vision, anothrr :: 
the methods of exploration, vix., anscolti :i-. Percussion is ni 't 
with a pleximeter, while the ear is applied to a cylinder of wc : 1. ?. 
stethoscope, placed in contact with the chest. This may be d:.:"i.- 
gnished as anseuUatory pereussicn. Its adTantages consist in :'ii 
better transmission of the sonorons Tibrations than when comn :r.:- 
cated thiongh the inteirention of the atmosphere, and in the gre TtI 
distinctness with which differences in the pitch and quality of s : - li 
are appredated. It is particolarly nsefnl in determining the ': : :j: - 
daiies of the solid organs, other than the lungs, which encroach on 
the thoracic space, ra., the heart, lirer, and spleen. Anscnlt?.t?ry 
percussion, howcTer, is rarely resorted to, becanse, for ordinary r :r- 
poses, the other and ampler miies sii^ce. In some inst:ii.:r5. 
for example, when it is desirable t: : 5 f : 7_ ^'r.\ t~:::::::t :li 
space occiq>ied by the hearty it may te iij-yr : :_ . ::: _r. 

In treating of the results of percussion we are to consider, firit, 
the phenomena pertaining to healtiii ; and, second, those which are 
to be regarded as the physical signs of disease. 



PERcrssiojT Ef Health. 

Percussion made on certain parts of the chest of a person in health. 
for instance at the summit, in front, derelopes a resonance which is 
peculiar. The quality of sound is highly characteristic, and 0:1:1- :: 
be well described, or illustrated by comparison. This quality, or 
timbre^ is due in a great measure to the fact that the air within the 
chest is contained in an immense number of minute spaces — the air- 
Tcddes. The sonorousness denotes the presence of air, and the con- 
trast, in this respect; is readily shown by percussing first the chest, 
and next a portion of the body composed of a solid mass of bone and 
zi^y ' : example the thigh. The peculiar quality of sound is ap- 
pxt .d. -t i>y percus^ng the chest, and afterward the abdomen, pro- 
vided the stomadi or intestines are somewhat flatulent. In the latter 
instance the sonorousness arises from the presence of gas iu a free 
space of considerable size. This species of resonance, in distinction 
fr^m that due to the presence of air in the lungs, is called ^772- 
panitie reMmianee. The same hollow quality of sound is elicited, 

> Mew Tadc Jomma of Medidne^ Juty, 1840. 



PERCUSSION IN HEALTH. 79 

for reasons wMcli will be presently mentioned, by perctissing certain 
portions of the thorax in health ; and it becomes also, as will be seen 
hereafter, under certain circumstances, a physical sign of disease. 
It is thus called in consequence of its type being the sound produced 
by percussing the abdomen distended by gas, in other words in a tym- 
panitic state. On the other hand, the sound peculiar to the chest may 
be distinguished as the pulmonary or vesicular resonance. The words 
pulmonary or vesicular, indicate the peculiar quality referred to. The 
latter, vesicular, is perhaps preferable, and I shall therefore employ 
it. In using the term, however, it is not to be understood that the 
character of sound would suggest a priori the existence of air-vesicles, 
but its appropriateness is based on the fact that the distinctive quality 
of the resonance is attributable to distention of the vesicles by air. 
In addition to its peculiar quality, the vesicular resonance has a certain 
pitch, and in this respect, compared with most abnormal sounds, it is 
low or grave. The sound also has a certain duration and degree of 
intensity. 

As regards the sonorousness in the four aspects just mentioned, 
viz., vesicular quality, pitch, duration, and degree of intensity, percus- 
sion practised in the same manner on the chests of different persons in 
health, by no means developes identical results. This may be demon- 
strated by placing a number of persons in a row, and percussing their 
chests, severally, in succession, in the same situations. The sound in 
no two of the persons, perhaps, will be exactly alike. It will present 
marked differences in the vesicular quality, in pitch, in duration, 
and in the degree of intensity. This is owing to differences in 
the elasticity of the thoracic walls, in the volume of the pulmonary 
organs, in the amount of muscular and adipose tissues covering the 
chest, and other circumstances not so easily appreciated. 

Nor is the percussion sound the same over every portion of the 
chest in the same individual. In corresponding situations, on the 
two sides of the chest, however, with certain exceptions, the pheno- 
mena developed by percussion are usually considered to be identical, 
or nearly so. This is a very important rule in its bearing on physical 
exploration. It may be said to be of fundamental importance in 
estimating certain variations from the normal sounds constituting 
the physical signs of disease, inasmuch as the latter are often deter- 
mined not so much by reference to an ideal standard of health, as by 
comparison of one side of the chest with the other side. As respects 
normal resonance, equality of the two halves of the chest, with some 



80 PHYSICAL EXPLORATION OF THE CHEST. 

exceptions is assumed. Were we not warranted in doing so to an 
extent sufficient for most practical purposes, it would sometime^ re 
extremely difficult to decide whether or not the phenomena devel:]:e:l 
by percussion denoted disease ; and the same is not less true of other 
methods of exploration than of percussion. But it is obviously im- 
portant to ascertain as completely as possible the deviations from this 
rule of equality, which may exist within the limits of health ; other- 
wise there is a liability that such dcTiations may be mistaken for the 
physical evidences of disease. As already intimated, there is room 
for investigations with reference to this poii.:. In order to determine 
to what extent and in what particulars disparity between correspond- 
ing portions on the two sides may be compatible with health, exami- 
nations are to be made of the chests of persons, selected for that pur- 
pose, who are presumed to be entirely free from pulmonary disease ; 
the phenomena must be carefully recorded, and a collection of facts thus 
obtained, subjected to analysis. I shall give, to some extent, results 
of such an investigation as regards percussion, and the other methods 
of exploration, the number of examinations not being large, but suffi- 
cient to establish certain deviations, and to illustrate the impoitance 
of a field of study which is by no means exhausted. We vrVA now 
proceed to a comparison of the several regions of the chest on the 
two sides respectively.^ 

1. Post-Claviculab REGiO]sr.^ — Percussion in this situation gene- 
rally elicits a pretty clear resonance, the vesicular quality being most 
marked in the central portion. Toward the sternal extremity, owing 
to the proximity of the trachea, the quality of sound is somewhat 
tympanitic, and this quality predominates in proportion as the direc- 
tion of the percussion-strokes is toward the trachea. The resonance 
in this region is greater in females than in males. It is very difficult 
to apply above the clavicles the finger used as a pleximeter equally 
on the two sides ; and if an ivory or other artificial instrument be 
employed, an inclination toward the trachea, slightly greater on one 
side than on the other, modifies the sound sufficiently to produce a 
disparity between the two regions in the pitch and quality of the 
resonance. In making comparative observations in healthy subjects, 

' The examinations of corresponding regions of the two sides, Ae results of which 
are given, were made in persons not only free from, all appearances of disease, bnt also j 
from any apparent deviation from the sjminetrical conformatkn <^the chest. Deibrmi- flH 
ties of the cbest, either congenital or resulting from disease, will, erf" cooxse, occasion dis- 
parity between the two sides in the phenomena developed by phj^ical exploratkm, as 
will be mentioned further on. 

2 For the boundaries of the regions, see Introduction, Section IL page 54, et seq. 



PERCUSSION IN HEALTH. 81 

I have found it almost impossible to produce uniform results with 
repeated percussions. This should enforce caution in regarding an 
apparent difference, if it be slight, as a morbid sign. To denote dis- 
ease, the difference must be well-marked and constant. With proper 
care, and making due allowance for disparity arising from inequality 
in the performance of percussion on the two sides, important evidence 
of the existence of disease is sometimes obtained by percussing in 
this situation, in cases of tuberculosis of the lungs. 

2. Clavicular Region. — Over the clavicles the resonance is 
somewhat tympanitic near the sternum, from the proximity of the 
trachea ; on the central portion, the vesicular quality is apparent, 
and at the acromial extremity the sound becomes comparatively dull. 
Equal percussion can be made on the two sides in this region, without 
difficulty. A slight disparity, however, is not unfrequently appreciable 
in health, and when the chest appears to be symmetrical, owing, pro- 
bably, to some difference in the size and curves of the bone. A slight 
difference in these respects in well-formed chests, is sometimes appa- 
rent on examination with the eye and by the touch. To be considered 
an evidence of disease, a disparity in the resonance should be well- 
marked, constant, and associated with a corresponding variation in 
the percussion-sound of the two sides, either in the post-clavicular 
or infra-clavicular regions, or in both. 

3. Infra-clavicular Region. — Percussion here elicits, gene- 
rally, a resonance more marked than elsewhere, save in the axillary 
region, and in some persons, below the scapula, behind. In this 
situation examination is to be made carefully for the physical signs 
of the early stage of tuberculous disease ; and a slight disparity in the 
percussion-sound, taken in connection with other signs, and with 
symptoms, is held to constitute strong evidence of a deposit of 
tubercle. With reference to the diagnosis of incipient phthisis, the 
deviations from the rule of equality at the summit of the chest, 
incident to health, are highly important to be taken into account. 
Of twenty examinations of persons apparently free from disease, and 
whose chests were symmetrical in conformation, in eight the percus- 
sion-sound was in all respects equal on the two sides, and in twelve, 
there existed disparity to a greater or less extent. The points of 
disparity noted were as follows. In ten, the degree of resonance 
was greater on one side than on the other. In all of these ten 
instances there existed a greater degree of resonance on the left side. 
In one instance, however, the resonance was greater on the right 

6 



82 PHYSICAL EXPLORATION OF THE CHEST. 

side, save at the portion near the sterno-clavicular junction ; at this 
portion it was greater on the left side. In eleven instances, em- 
bracing all the ten persons just referred to, and one in addition, the 
pitch of resonance was somewhat higher on the right than on the 
left side.^ In one of these cases, the same mentioned above, the 
pitch was higher at the sterno-clavicular junction on the right and 
over the rest of the region on the left side. In four instances, it 
is noted that the vesicular quality of the resonance was greater on 
the left side, and in no instance was this observed on the right side. 
Pains were not taken to observe and note this point in all the 
examinations. The resonance was relatively tympanitic^ in its 
character on the right side in one instance, and in one, also, on the 
left side ; with respect to the duration of sound, observations were not 
made ; the disparity in degree of resonance and pitch found in the 
majority of instances, was generally slight, but sufficient to be dis- 
tinctly appreciated on repeated careful percussion. It thus appears 
that in the majority of persons in health, having well-formed chests, 
there is not an absolute equality in the resonance existing at the 
summit of the chest in front on the two sides. It appears, also, 
that, as a general rule, the disparity consists in a greater degree of 
resonance, more vesicular quality, and, relatively, lowness of pitch, 
on the left side. The tympanitic quality is occasionally found on 
one side, which may be either the left or the right. The practical 
bearing of these facts will appear hereafter ; the facts rest on obser- 
vation, and are independent of any explanation that may be offered. 
Theoretically, in view of the greater capacity of the right chest, it 
would seem perhaps more reasonable that the difference between 
the two sides should be the reverse of that which is found to exist. 
The larger development of the right pectoral muscle, in consequence 
of the greater use of the right upper extremity, may account for the 
fact in some instances, but the disparity exists in cases in which 
there is no apparent difference in the muscular covering, in this 

^ These results, as respects pitch, differ verj- considerably from those obtained in twenty- 
two examinations made with reference to this point in 1852. (Prize Essay, by author.) 
In these twenty-two examinations disparity of pitch in this region was noted in two 
instances only. The ratio of instances in which points of disparity are presented 
would be expected to differ somewhat in different collections of cases, but so great a 
difference would not have been anticipated. I am disposed to explain it in part by 
the fact that the more recent examinations were made with a greater closeness of 
observation, in order to appreciate the slightest degree of disparity. 

2 By the term tympanitic, I mean a non-vesicular sound, without reference to 
intensity. 



PERCUSSION IN HEALTH. 83 

situation. Possibly the different physical conditions at the base of 
the thorax may afford an explanation. On the right side the lungs 
repose, with the diaphragm intervening, on the liver, which occupies 
the whole of the base on that side. The presence of this solid viscus 
may slightly deaden the sound. On the left side below the lung is 
situated the stomach, frequently more or less distended with gas, 
and the effects of this, it may be supposed, is to increase the 
sonorousness on that side, even at the summit, independent of the 
transmission of the tympanitic gastric sound which is sometimes ob- 
served. 

4. Scapular Region. — I enumerate this region next to the pre- 
ceding because, being at the summit of the chest, its relations 
in diagnosis are similar. Like the infra-clavicular, it is an impor- 
tant region with reference to the physical signs of phthisis. The 
normal degree of resonance over the scapula is much less than at 
the summit in front, for sufficiently obvious reasons. The vesicular 
quality of resonance is less apparent. A distinct sonorousness, how- 
ever, exists here, notwithstanding the percussion has to be made on a 
layer of bone, and a mass of muscle placed upon it. These cir- 
cumstances do not deaden the sound sufficiently to render the region 
nearly or even quite unimportant in physical exploration, as stated 
in a recent work on diseases of the chest.^ On the contrary, percus- 
sion in this situation is often of great utility in the diagnosis of 
tubercle. The region is subdivided into the supra and infra spinous 
portions. The sonorousness is greater over the latter. 

In thirteen of twenty observations, relative to the comparative 
resonance in the scapular region, on the two sides of the chest, no 
disparity was apparent. In four of twenty observations, the reso- 
nance was less on the right than on the left side. In a single instance 
the resonance was greater on the right side. In the latter case there 
was tympanitic resonance in front and laterally. In three instances 
it was noted that the pitch of resonance was higher on the right side. 
In two instances this was true of the left side. In both the latter 
instances tympanitic resonance existed in front on the left side. In 
two instances the resonance was tympanitic over the left scapula, and 
in no instance was this noted of the right. 

Disparity between the two sides thus appears to be present in a less 
proportion of cases at the summit behind than in front. When pre* 

' Swett on Diseases of the Chest. 



84 PHYSICAL EXPLORATION OF THE CHEST. 

sent, however, the general rule is the same, viz., less sonorousness, 
and a higher pitch on the right side. 

5. Interscapular Region. — In this region a certain amount of 
sonorousness exists, notwithstanding the mass of muscular substance. 
Without having preserved recorded observations, I should say, in 
general, the degree of sonorousness is greater than in the scapular 
region below the spinous ridge, although Walshe states that, in 
this respect, it holds an intermediate place between the infra and 
supra spinous spaces. The vesicular quality of sound is feeble. The 
degree of sonorousness is less, and the pitch higher on the right side 
in some persons, but I have not taken pains to obtain data bearing 
on the ratio of instances in which disparity in these points is to be 
observed. 

6. Mammary Region. — The mammary region offers marked differ- 
ences on the two sides, owing to the presence of the upper convex 
extremity of the liver, covered with lung substance, in the right, and the 
situation of the heart in the left side of the chest. From the fourth rib, 
on the right side, diminished resonance is appreciable, which increases 
as percussion is made downward to the point where the pulmonary 
sound ceases. This point marks what may be called the line of 
hepatic flatness, i. e. the lower border of the lung. This point, which 
is somewhat variable in different persons, usually falls a little below 
the lower boundary of the mammary region, or the sixth rib. Next 
to the sternum, on this side, between the third and fifth ribs, the 
presence of a portion of the right auricle and ventricle, occasions 
diminished sonorousness over a space extending about a finger breadth 
from the right margin of the sternum. 

On the left side, diminished resonance exists in the prsecordial 
space, and over a portion of this space, in which the heart is in contact 
with the thoracic walls, there is almost complete absence of sonorous- 
ness. Percussing in a vertical direction from above downward, midway 
between an imaginary line passing through the nipple, and another line 
coincident with the left margin of the sternum, diminished resonance 
exists at the upper border of the mammary region, viz., the third rib. 
At the fourth rib, on a horizontal line passing through the nipple, reso- 
nance nearly ceases, in consequence of a portion of the heart in this 
situation being uncovered by lung. From the fourth to the sixth 
ribs, the absence of resonance continues, and extends more and more 
to the left of the sternum, the inner border of the left lung receding, 
so as to leave the heart in contact with the wall of the chest over a tri- 



PERCUSSION IN HEALTH. 85 

angular space, the widest part of which is indicated by a horizontal line 
touching the fifth rib at a point a little within the nipple. Percuss- 
ing horizontally from the sternum outward on a line passing through 
the nipple, resonance is nearly absent to within about a finger's 
breadth of the nipple. Diminished resonance, however, is appreciable 
quite to the nipple, and even a little beyond it, owing to the fact that 
the heart extends thus far covered by lung. The presence of the 
heart in the left side thus gives rise to alterations in the percussion- 
sounds which are twofold. First, absence, nearly or quite, of vesicu- 
lar resonance. This is the case over the space in which the left lung 
fails to cover the organ. Second, diminished resonance over an area 
extending a certain distance beyond the boundaries of that space. 
The precise limits of these two areas are important in connection 
with the study of diseases of the heart. Variations in the degree 
of resonance in the praecordia are also involved in the diagnosis of 
pulmonary affections. In health the degree of resonance is different 
with the two acts of respiration, and may be affected voluntarily by 
increasing the extent of inspiration and expiration. By inspiration 
a larger portion of the heart is covered by lung than in expiration ; 
on the one hand, the space covered by means of the former, and, on 
the other hand, that uncovered by means of the latter act, other 
things being equal, are proportioned to the forced expansion of the 
lung, and the contraction alternating with the two acts. A morbid 
condition of the lung, consisting in permanent distension of the air- 
cells (which obtains in emphysema), will, of course, diminish the space 
over which, in health, resonance is nearly or quite absent. Abnormal 
resonance in the prsecordia, hence, becomes a physical sign of that 
affection. On the other hand, atrophy of the lung would have a con- 
trary effect. Considerable differences as respect the extent to which 
the resonance is diminished, and also the limits of the two areas are 
observed in different persons in Avhom the lungs are perfectly healthy. 
In other words, the lung overlies the heart more in some individuals 
than in others, of which fact percussion furnishes physical evidence. 

The mode of performing percussion in order to develope, first, the 
flatness due to the contact of the heart with the thoracic wall ; and, 
second, the dulness occasioned by the presence of that portion of the 
organ which is covered by the lung, is somewhat different ; and this 
difference, which involves a rule applicable to the practice of percus- 
sion in other situations, both in health and disease, may as well be 
mentioned in the present connection. In determining the space which 



86 PHYSICAL EXPLORATION OF THE CHEST. 

the heart occupies, uncovered by lung, percussion should be lightly 
made ; but to fix the boundaries to which the organ extends covered 
by lung, beyond this space, greater force of percussion is requisite. 
The diiference in the practical results of these two methods of 
percussing was first pointed out by Piorry. In general, a light 
percussion reveals physical conditions pertaining to parts situated 
directly beneath the thoracic walls ; while a more forcible percussion, 
the blows being made to bear on parts more deeply seated, is neces- 
sary to obtain information of the physical condition of parts situated 
more or less beneath the surface of the lung. To the first mode, 
Piorry gives the name of superficial percussion ['percussion superfi- 
cielle) ; and the second mode he calls deep percussion (percussion 
profonde). Forcible or deep percussion is necessary to determine 
the existence and the size of indurations of lung from partial pneu- 
monia, pulmonary apoplexy, or tuberculous deposit, which are re- 
moved, to a greater or less distance, from the surface of the lung. 

Although a portion of the heart is in actual contact with the 
thoracic walls, the percussion-sound over this space, is rarely totally 
devoid of resonance, i. e. absolutely flat. This is probably owing to 
the fact that the percussion, more especially when made on a rib, in 
consequence of the elasticity of the latter, is not limited in its effects 
precisely to the point percussed, but extends over a greater or less 
area, and is thus brought to bear on the lung in near proximity, 
sufficiently to produce some degree of sonorousness. In this fact 
may be found an explanation of the superiority of light strokes in 
ascertaining the condition of parts situated directly beneath the points 
of the chest on which the percussion is made. As a general rule, the 
average area of dulness in the prsecordia, may be stated to be about 
two inches in diameter, measured transversely by a line passing 
through the nipple. 

The mammary region affords a degree of resonance considerably 
less than the region situated above it, the infra-clavicular, for reasons 
other than those already mentioned. The pectoral muscle diminishes 
the sonorousness ; and the difference in the bulk of this muscle, in 
different persons, is a cause of the differences in the degree of 
resonance observed in this region within the limits of health. In the 
female, the mammary gland tends still more to deaden the sound, 
and in the size of this gland, it is well known different females present 
a very wide range of difference. It is an error, however, to say that, 
on this account, the mammary region, in females, "is of no value in 



PERCUSSION IN HEALTH. 87 

percussion."^ Even when the mamma is unusually large, an abnormal 
degree or kind of resonance may be determined in this situation 
sufficiently for the practical objects of diagnosis. In making percus- 
sion over the mammary gland, the ivory pleximeter may be used with 
advantage. With its broad smooth surface the soft parts may be 
compressed more firmly, and the strokes brought to bear more effi- 
ciently on the thoracic walls. 

The left mammary region sometimes yields a tympanitic sound on 
percussion, due to the presence of gas within the stomach. 

7. Inera-Mammaey Region. — In this region, as well as in the pre- 
ceding, the two sides naturally present marked disparity as regards 
percussion-sounds. Over nearly, and in some persons quite, the 
entire region on the right side, there is absence of sonorousness, 
owing to the situation of the liver. This fact is not unfrequently 
overlooked by persons but little accustomed to physical exploration, 
and the want of resonance attributed to intra-thoracic disease. In- 
stances of this error have often fallen under my observation. The 
line marking the lower anterior extremity of the right lung, in other 
words the line of hepatic flatness ^ varies considerably within healthy 
limits. Determined by percussing downward on a vertical line passing 
through the nipple (the persons standing or sitting), the point at 
which resonance ceases, in the majority of instances, will be found 
over the seventh rib. Not unfrequently, however, it is over the 
sixth, and occasionally, as low as the eighth rib. Of fourteen exami- 
nations made with reference to this point, in nine, hepatic flatness 
commenced with the seventh rib ; in four, with the sixth rib, and in 
one instance with the eighth rib. The line of hepatic flatness now 
referred to, is that existing with ordinary respiration. Even with 
ordinary respiration the line is not fixed, owing to the play of the 
diaphragm with the two respiratory acts. This may be thus shown : 
the finger employed as a pleximeter may be placed at a certain point, 
where, continuing for some time repeated percussions, with some of the 
strokes a resonance will be observed, and with others none whatever. 
But forced acts of inspiration and expiration, in consequence of the 
convexity of the diaphragm with the former, and its depression with 
the latter act, afiect considerably the point at which resonance ceases. 
If the line of flatness in ordinary respiration be over the sixth rib, 
the efi"ect of a deep inspiration is to lower it to the seventh rib ; and 
if, in ordinary respiration, the line is on the seventh, it is depressed 

^ Swett on Diseases of the Chest. 



88 PHYSICAL EXPLORATION OF THE CHEST. 

to the eighth rib. In the instance in which the line with ordinary 
respii-ation lay on the eighth rib, it was depressed to the ninth. The 
distance to which it may thus be Tolimtarily carried downward, is 
pretty uniformly about IJ inches. On the other hand, by forced 
expiration the line of flatness is elevated to an extent less uniform in 
different persons. It is carried upward to the sixth, fifth, and fourth 
ribs, the distance varying from 2J to 5J- inches. The distance from 
the line of hepatic flatness after a deep inspii'ation to that after a 
forced expiration, in different persons, varies from 4 to 7 inches. 
This distance is a pretty good criterion of the breathing capacity of 
the individual. 

Above the line of flatness, on making forcible percussion, notably 
diminished vesicular resonance, or well-marked dulness, extends up- 
ward for one or two inches. This is caused by the convex upper 
sm-face of the liver, covered by the thin extremity of the right lung. 

A tympanitic resonance is sometimes but rarely produced by per- 
cussing over the liver, due to the presence of gas in the intestinal 
canal. 

In the left infra-mammary region the percussion-sound not only 
varies in different persons but in the same person at different times ; 
and also indifferent portions of the region at the same time. These 
variations depend on the different organs below the diaphragm which 
encroach on the lower division of the thorax. Into the right portion 
of the region, the left lobe of the liver extends to an extent somewhat 
variable, generally, according to Piorry, two inches to the left of the 
median line. Light percussion over this portion elicits a flat sound, 
or at all events, absence of vesicular resonance. The left boundary of 
the liver may generally be defined by the percussion-sound. Beneati: 
the left portion of the region lies the spleen, an organ, the volume of 
which, as is well known, varies considerably within the limits of 
health, and in certain diseases (typhoid and intermittent fever), be- 
comes enlarged to a greater or less extent. Frequently, if not gene- 
rally, the space occupied by this organ, both in health and disease, 
may be determined by percussion. Its average dimensions, according 
to the observations of Piorry, are about four inches in length, and 
three inches in width. The stomach is situated between the two solid 
organs just named, and this organ is constantly fluctuating as regards 
degree of distension, and the nature of its contents. Enlarged by 
the presence of gas, it occasions a tympanitic resonance frequently 
pervading the whole infra-mammary region, and sometimes extending 



PERCUSSION IN HEALTH. 89 

the mammarj. The sound is characteristic, and may be distin- 
;uished as the gastric tympanitic resonance. It is high in pitch, and 
ften has a ringing metallic tone. These characters are rendered 
bvious by contrasting it with the tympanitic resonance elicited by 
)ercussion over the intestines. The percussion-sound over the lower 
)art of the left side of the chest is generally more or less modified 
)y the presence of gastric tympanitic resonance. On the other 
and, when the stomach is filled with solid or liquid alimentary sub- 
tances, the percussion-sound is dull or flat. 

8. Sternal REaiONS. — These regions are single ; that is, they do 
iOt, like the regions already referred to, consist of corresponding 
iivisions of the thorax situated on either side of the mesial line. On 
;his account, and in consequence of the sternum forming a continuous 
)ony covering, devoid of the elasticity belonging to the ribs, emitting 
m osseous sound when struck, and, moreover, over the greater part 
)f its extent other organs than the lungs lying beneath, it is rarely 
;he case that much important information respecting pulmonary dis- 
ase is here obtained by means of percussion. Over the greater 
)ortion of the upper sternal region, viz., above the lower margin of 
he second rib, there is more or less sonorousness, which is non- 
i^esicular in character, being due to the air contained in the trachea 
ibove the point of bifurcation. From the character of the sound it 
s sometimes distinguished as tubular sonorousness^ but for all prac- 
tical purposes, it sufiices to consider it a modification of tympanitic 
resonance. Below the point of bifurcation, i. e. from the second to 
the lower margin of the third rib, the inner border of the lungs on 
the two sides approximate, and the resonance may present more or 
less of the vesicular quality. The remnant of the thymus gland, 
and the deposit of adipose substance, however, sometimes render 
the percussion-sound dull or even flat in this situation. The pre- 
sence of the large vessels leading from the heart conduces to the 
same result. 

Over the lower sternal region, i. e. from the lower margin of the 
third rib, the combination of several difi'erent organs occasions 
various modifications of resonance. Beneath the region are, 1, a 
portion of the right lung, lying to the right of the mesial line ; 
2, the greater part of the right ventricle of the heart, and a 
portion of the left ; 3, at the lower part a portion of the liver ; and 
4, occasionally, where distended, a portion of the stomach. It is 
obvious that the percussion-sound must vary in difi'erent parts of 
the region, and present often a mixed character. By care and 



90 PHYSICAL EXPLORATION OF THE CHEST. 

tact in percussion, however, it is practicable frequently, if not gene- 
rally, to define the boundaries of the several organs which are 
embraced in a section of this region, by means of the distinctive 
sounds pertaining to them respectively. This, which, according to 
Walshe, "is one of the most difficult practical problems in the 
art of percussion," involves a question of some interest and impor- 
tance in its bearing on physical exploration, to which reference has 
not yet been made, and which may be briefly noticed in the present 
connection. The question is. Do the different solid organs of the 
body, the liver, heart, spleen, kidney, etc., yield, on percussion, 
sounds distinctive in character ? Piorry, assuming the affirmative of 
this question to be true, has described a series of sounds, each of 
which he regarded as characteristic of the organ lying beneath the 
point percussed. Thus according to him, there is a liver-sound, a 
spleen-sound, etc., and each of these distinctive sounds is supposed to 
depend on the molecular arrangement belonging to the structure of 
the particular organ. The correctness of the opinion just stated is 
denied by Skoda.^ According to this author, "there is no difference 
in the percussion-sound by which we can distinguish between organs 
not containing air, such as the liver, the spleen, the kidneys, hepatized 
lung, or lung completely deprived of air by compression, and fluids ; a 
hard liver yields the same sound as a soft liver, a hard spleen as a 
soft spleen, and blood the same sound as pus, water, etc. We may 
readily convince ourselves of the fact, by placing these different 
organs on a non-resonant support, and percussing them one after 
the other, either with or without a pleximeter ; fluids, similarly sup- 
ported and in sufficient quantity, may also be percussed by aid of a 
pleximeter, carefully applied to their surface."^ Walshe makes a 
similar statement.^ Others have arrived at an opposite conclusion 
by means of the very experiments cited by Skoda, and contend that 
of the different solid organs, and different fluids, each has its 
peculiar sound, as the wood of various species of trees may be distin- 
guished from each other by percussion, or as bone and cartilage 
differ in this respect, according to Skoda* himself. This point of 
physics is of less consequence than may at first appear, inasmuch as 
the question whether the several organs named have not peculiarities 

• A Treatise on Auscultation and Percussion, by Dr. Joseph Skoda. 
2 Translation, by W. C. Markham, M.D., London edition, page 5. 
^ Op. cit. 

4 See note to French translation of Dr. Skoda's treatise, by the translator, Dr. F. A. 
Aran, page 6. 



PERCUSSION IN HEALTH. 91 

f sound in situ by no means hinges upon it. Skoda and Walshe do 
lot deny distinction of percussion-sound pertaining to these organs 
IS they are situated in the body, but they account for the difference 
Tom the relations of the organs to neighboring parts which contain air, 
m., the lungs, stomach, and intestines. The question, therefore, may 
)e settled by the result of examinations practised on living and dead 
subjects. Facts thus obtained undoubtedly establish the existence 
of distinctive sounds by which the sites of the different organs may 
be determined and their boundary lines often mapped out. For 

xample, the sound produced by percussing over the liver differs 
obviously from that elicited over the heart : the latter is less flat 
and higher in pitch. It is highly probable that this difference is 
due to the disparity in size of the two organs, and the parts in 
juxtaposition, rather than to intrinsic peculiarities of the organs 
alone. The fact of the difference, however, exists irrespective of 
the explanation. The peculiarities of sound emanating from solid 
organs are probably more sharply defined, and appreciated with 
much greater facility, by employing " auscultatory percussion,'''^ than 
by percussing in the ordinary mode. The practice of ordinary 
percussion, which is more simple, and therefore more readily 
available, with a view to determine and mark out the bounda- 
ries of the different solid organs encroaching on the chest, is an 
exercise to be highly recommended, not only as a means of becoming 
familiar with the characteristic sounds of each, but as tending to 
impress on the mind the relative situations of these organs, and at 
the same time, conducing to practical skill in the use of the method 
of physical exploration under present consideration. To this applica- 
tion of percussion Piorry has given the title of organographisme. 

9. Infra-Scapular Eegions. — Percussion posteriorly, below the 
scapula, generally yields a marked degree of vesicular resonance. 
The larger portion of the inferior lobe being embraced in this region, 
and a very small portion only of this lobe extending into the anterior 
part of the chest, it is here especially that exploration is made for 
the physical signs of inflammation of the lungs or pneumonia, the 
lower lobe being the one affected in the great majority of cases of 
that disease. The point to which the lower extremity of the pul- 
monary substance extends is over the eleventh rib. On the right side 
the line of hepatic flatness commences at or near this point, varying 
somewhat, as in front, in different persons. This line, as in front, is 

' See Essay by Dr. Cammann and Clark, previously referred to. 



92 PHYSICAL EXPLORATION OF THE CHEST. 

depressed from one to two inches by a deep inspiration and elevated to 
a greater or less extent by a forced expiration. Here, too, as in the 
right infra-mammary region, above the line of flatness in ordinary 
respiration, a marked degree of dulness on percussion is appreciable 
for a distance of from one and a half to two inches. On the left side 
the resonance may be more or less tympanitic, from the presence of 
gas in the stomach. Below the eleventh rib there may be tympanitic 
resonance from intestinal gas ; and near the spine the limits of the 
left kidney, which is here situated, may be indicated by the percussion- 
sound ; possibly, also, at the outer side of the lower part of the 
region, the space occupied by the spleen may in some instances be 
determinable. 

10. Lateral Regions. — The axillary region on both sides is 
highly sonorous on percussion, the vesicular quality usually being 
strongly marked. The infra-axillary region generally presents more 
or less disparity on comparison of the two sides. On the right side, 
near the sixth or seventh rib, the absence of resonance denotes the 
line of hepatic flatness, the situation of the line being subject to 
the same depression and elevation, with inspiration and expiration 
voluntarily increased, as in front and behind. Dulness for a 
short distance above this line is also here marked. On the left side 
the percussion-sound may be more or less deadened by the presence 
of the spleen ; but it is much oftener rendered tympanitic by the 
presence of gas within the stomach. Crossing the infra-axillary 
region diagonally is the interlobar fissure, which, although not deter- 
minable in health, may be traced by means of percussion in disease 
(pneumonia), a fact of importance in diagnosis. 

Reviewing the regions which have just been considered in connec- 
tion with the phenomena developed by percussion in a state of health, 
it will be seen that the following, as regards the intra-thoracic organs 
embraced within their limits respectively, are nearly similar or sym- 
metrical on the two sides of the chest : anteriorly, the supra-claAdcular 
and infra-clavicular regions ; posteriorly, the scapular and interscapu- 
lar regions; laterally, the axillarj^ region. The remainder, viz., the 
mammary and infra-mammary, the infra-axillary and the infra-sca- 
pular, present anatomical points of dissimilarity attended by a want 
of correspondence in the physical phenomena produced by the method 
of exploration under consideration, as well as the other methods 
remaining to be considered. The regions, however, which in an 
anatomical point of view are similar, or nearly so, do not invariably, 



PERCUSSION IN HEALTH. 93 

as has been seen, yield identical percussion-sounds, but to a certain 
extent deviations occur entirely compatible with health. In order to 
ettle with precision, numerically, the ratio of instances in which these 
i^ariations may be expected to be found, an accumulation of further 
statistical data is necessary. Moreover, these variations appear in 
some measure to observe certain laws. Knowledge of the variations, 
ind of the laws by which they are influenced, is important in its 
)earing on the diagnosis of disease, as will be seen hereafter. 

In instituting comparisons of the corresponding regions of the two 
ides, hitherto, it has been assumed that the chest is free from dis- 
)arity resulting from deformity or previous disease, in other words, 
hat the two sides are symmetrical in conformation. But instances 
)resenting deviations from anatomical symmetry, as has been seen 
Introduction, Sect. I), are of frequent occurrence. In the practice of 
)ercussion, and other methods of exploration, it is necessary to take 
jognizance of the points of dissimilarity which are determined by the 
nethod of inspection. This is a rule of fundamental importance in 
)hysical diagnosis. The most prominent causes of visible altera- 
ions in the symmetry of the two sides of the chest, as already 
tated, are spinal curvature, rachitis, fractures, prolonged pressure 
►n the thorax in infancy, tight lacing, and contraction after chronic 
)leurisy. The existence or non-existence of alterations from the 
peration of these or other causes is always to be ascertained, and 
aken into account in drawing inferences from points of contrast 
rhich the physical phenomena pertaining to the two sides may offer. 
Allusion has been made to various circumstances occasioning in 
ifferent healthy persons wide differences in the intensity and other 
haracters of the percussion-sound, viz., the greater volume of the 
angs in some individuals than in others ; greater elasticity of the 
horacic walls ; varying amount of muscular development as well as 
dipose deposit, etc. Age has a certain influence. Other things 
eing equal, in consequence of the greater elasticity of the costal 
artilages in early life, the degree of resonance is greater than at a 
iter period, when the cartilages become stiffened, or rigid from 
ssification. As a general rule, probably, the pitch is lower and the 
ense of resistance is less in the former case. In old age, the vesi- 
ular quality of the resonance is impaired by the atrophied con- 
ition of the lung incident to advanced years, and the sound as- 
ames somewhat a tympanitic character. 
The percussion-sound may also be found to vary at different periods 



94 PHYSICAL EXPLORATION OP THE CHEST. 

contained within the air-cells, and consequently the relative proportion 
of air and solids, are by no means equal after a full inspiration and 
after a forced expiration. This difference in lung expansion may 
occasion an appreciable disparity in resonance, according as the 
percussion is made at the conclusion of a full inspiration, or a forced 
expiration. The disparity is not appreciable uniformly in different 
persons. This fact I have ascertained by noting the results of exami- 
nations made with reference to the point. When it does exist, it 
usually consists, contrary to what might perhaps have been antici- 
pated, and the reverse of what is usually stated in works on physical 
exploration, in diminished resonance and elevation of pitch at the 
conclusion of inspiration. This is probably to be explained by the 
greater degree of tension of the lungs and thoracic walls produced by 
inspiration voluntarily prolonged and maintained — a condition pre- 
senting physical obstacles to sonorous vibrations more than sufficient 
to counterbalance the increased proportion of air within the cells 
It is a curious fact, worthy of notice, that the two sides of the ches 
are not always found to be affected equally as regards the percussion 
sound, at the conclusion of a full inspiration, contrasted with that afte 
a forced expiration. I have observed the contrast to be more strikin 
on the right than on the left side ; and in one instance on the left sid 
the resonance was less intense and somewhat tympanitic after a ful 
inspiration, while on the right side, the opposite effect was produced, 
and the sound became quite dull after a forced expiration. I 
view of these variations in a certain proportion of instances inciden 
to different periods of a single act of respiration, in some cases o| 
disease in which it is desirable to observe great delicacy in the co: 
respondence of the two sides, pains should be taken to percuss cor 
responding points at a similar stage of respiration, and the clos 
of a full inspiration is, perhaps, the period to be preferred. Ordi 
narily, the liability to error from this source is obviated, either b 
repeating a series of strokes, first on one side and next on the othei 
or by percussing both sides repeatedly in quick succession, in orde 
mentally to obtain the average intensity and other characters 
the sound during the successive stages of a respiration. The 
stances of disease, however, are exceedingly rare, in which sue 
nicety of discrimination is important. 

Certain rules of manipulation, pertaining to the practice 
percussion, have already been stated. Others important to 
borne in mind remain to be mentioned. These practical rules a: 



PERCUSSION IN HEALTH. 95 

qually applicable to examinations of the chest in health and disease ; 
nd it will not, therefore, be necessary to recur to this subject in con- 
ection with the morbid signs developed by percussion. 

In percussing different portions of the chest it is not a matter 

f indifference in what position the person examined, is placed. To 

xplore the anterior surface of the chest the position most favorable 

elicit Sonorousness is standing, the shoulders thrown moderately 

ackward, and the back resting against some firm support ; next to 

lis is a sitting posture, the back in like manner supported. A re- 

umbent position, although less favorable, is frequently the only one 

vailable in cases of disease, owing to the weakness of the patient. In 

ach of these three positions the upper extremities should be equally dis- 

osed by the side of the body, the shoulders maintained on the same 

?vel, as nearly as possible, and the two sides of the chest on the 

ame plane. Particularly in the recumbent posture, care should 

taken that the bed and pillows be so arranged as to avoid any 

lequality affecting one side more than the other. For an examination 

f the posterior surface in the most satisfactory manner, the patient 

mst assume a sitting posture, the body inclined a little forward, the 

rms brought forward, and folded so as to render tense the muscles 

ttached to the scapula. An imperfect exploration, but frequently 

iifficient for the objects of diagnosis in cases of disease precluding 

le sitting posture, may be made of the two sides in succession, the 

atient lying first on one side and then on the other ; or it may be 

racticable sometimes for the patient to rest on the abdomen. In 

ercussing the lateral surfaces, the posture may be standing, sitting, 

r recumbent, the hands, with the fingers interlocked, resting on the 

)p of the head. 

The position of the explorer is also a matter of consequence. If 

, le person examined stand, it is of course necessary to take the same 

osition. If, however, the patient be seated, or recumbent, the ex- 

mination will be most conveniently made in the sitting posture. It 

I ; well to be placed as nearly as possible in front of the mesial line, 

1 order to receive the percussion-sounds from each side of the chest, 

t an equal distance. If, however, a lateral situation be preferred, 

necessary, with reference to the same end, pains should be 

iken, wherever a delicate comparison is made, to pass from one side 

the other, so as to percuss on corresponding points, whilst in a 

milar relative position to the patient. Identical sounds reaching 

le ear from unequal distances may appear to differ in intensity, if 

ot in other respects. 



I 



96 PHYSICAL EXPLORATION OF THE CHEST. 



The manner in which the strokes are to be made in percussing 
has been already described. If the finger or fingers of the left 
hand be the pleximeter employed, they may be placed horizontally 
on the chest, first on the ribs, and next, in the intercostal spaces ; 
or vertically, at right angles with the ribs. Whenever careful 
percussion is required, both positions should be resorted to. In 
percussing the acromial portion of the infra-clavicular rfgion the 
most convenient disposition is to place the fingers in a diagonal direc- 
tion. It is better to place the palmar surface of the fingers in appo- 
sition to the chest, and strike on the dorsal surface, although the 
reverse is practised by some who are distinguished in the art of 
physical exploration. I 

Percussion is to be made on corresponding points of each side of the r 
chest alternately, care being taken to strike on the ribs, or the inter- r 
costal spaces successively, and to compare the sound elicited from the :f 
two sides. As already stated, deviations from healthy sounds are de- | 
termined generally by means of this comparison, and not by reference r 
to any fixed standard. Hence, the difierences natural to the chest of f 
difierent persons do not affect the value of percussion in developing r 
signs of disease. It is therefore important, that the percussion be 
made in every respect as equally as possible on the two sides. The f 
same degree of force is to be given to the strokes ; they are to be made 
in the same direction, and, in short, so far as practicable, in precisely f 
a similar manner. By the non-observance of due precaution on this 
point, it is easy to produce a disparity in the percussion-sounds, in 
cases in which there is in reality no diiference as respects the physical _ 
conditions on whix;h the sonorousness depends. For example, suppose- 
percussion to be made in the infra-scapular region ; and let the strokes 
on one side be made with the ends of the fingers, in a direction 
opposite to the spinal column, and the movement favorable for the pro- 
duction of the highest amount of resonance ; then, directly after- 
ward, on the other side, let the strokes be made with the pulpy por- 
tion of the fingers, in a direction toward the spinal column, and the ' 
movement intentionally modified so that the fullest amount of resonance i 
shall not be produced, the disparity between the two sides will be ' 
marked, and yet, if such an experiment be not watched by a critical, 
observer, the difi"erence in the mode of percussing will not be de-^ 
tected. A difference in simply the force of percussion on one side, 
in any situation, while the muscular effort appears to be similar, and 
in all other respects the blows are identical, will suflSce to occasion 



PERCUSSION IN HEALTH. 97 

an obvious disparity in sound. Hence, before deciding on the actual 
existence of a slight disparity, percussion should not only be made 
with great care, but repeated often enough to obviate the liability 
to deception by a failure to strike with equal force on corresponding 
points. 

That the eye may select points which correspond on the two sides, 
and the better to secure uniformity in the act of percussing, it is 
preferable, in cases in which nicety of discrimination is required, to 
divest the chest of all covering. In the female, this is opposed by a 
regard for delicacy. The end may, however, be attained without 
offending propriety by uncovering portions of the chest at a time, 
and not exposing the mammse, which is rarely if ever necessary. 
In many instances the objects of physical exploration may be 
accomplished without the necessity of denuding any portion of the 
chest. 

In addition to the sounds produced by percussion, important in- 
formation may sometimes, at the same time, be obtained by direct- 
ing attention to the sense of resistance, felt by the fingers when 
struck. In proportion as the walls of the chest areldeprived of their 
elasticity, or the parts contained within the thorax are unyielding to 
pressure, a sense of resistance will be appreciable by the finger on 
which percussion is made. In the healthy chest this is rendered 
very apparent by percussing in the right infra-mammary region, 
where hepatic flatness exists, and contrasting the resistance with 
that felt in percussing either at the upper part of the chest on the 
same side, or on the lower portion of the left side of the chest. A 
disparity in this respect between corresponding points in which an 
equality should naturally exist, becomes a physical sign of disease. 

Finally, the following rule may be repeated, viz., to ascertain the 
physical condition of the superficial portion of the intra-thoracic 
organs, the percussion-blows should be light ; but to determine a dis- 
parity dependent on deep-seated alterations, forcible percussion is 
requisite. In connection with this rule, it is to be stated that ordinarily 
in the practice of percussion, delicate strokes, which do not occasion 
pain, nor present an appearance of roughness, answer every practical 
purpose. 

The facts and rules which have thus been given under the head of 
Percussion in Health are commended to the attentive consideration 
of the student before entering on the study of Percussion in Disease. 

7 



98 PHYSICAL EXPLORATION OF THE CHEST. 

After becoming familiar with all that has already been presented 
relative to percussion, and practically expert by resorting to exa- 
minations of healthy chests, the knowledge of the morbid signs 
developed by this method, and its application in the diagnosis of 
thoracic affections, are easily attained. In fact, to so great an ex- 
tent may the physical phenomena of disease be studied in health, 
that, after, such a preparation, the subject offers no difficulties. 



Percussion in Disease. 

The various physical changes incident to disease affecting the intra- 
thoracic organs occasion corresponding modifications of the sound 
elicited by percussion, and hence, the latter become the signs of the 
former. The more important of the physical changes incident to 
different forms of disease, are the following : over-distension of the 
pulmonary vesicles, involving usually abnormal expansion of the 
chest, and a greater degree of tension than belongs to health ; undue 
reduction in the quantity of air, associated with more or less in- 
creased density of lung, from the deposits of effused blood, serum, 
coagulable lymph, tuberculous or other morbid products; the pre- 
sence of air or liquid, or both, in excavations or cavities, formed 
at the expense of the pulmonary substance ; liquid of different kinds 
in the pleural sac, compressing the lung, and sometimes supplanting 
it entirely; and air or gas contained between the surfaces of the 
pleurse, generally with, at the same time, a greater or less propor- 
tion of liquid. Certain physical phenomena, ascertained by per- 
cussion, as well as the other methods of exploration, are found by 
clinical observation to accompany the foregoing morbid conditions, 
and on the constancy of the connection between these phenomena 
and morbid conditions, establishing the relation of cause and effect, 
depend the significance and value of the former as indices of the lat- 
ter. Resonance of the healthy chest, has been seen to involve the 
following elements, viz., a certain amount of intensity, or loudness ; 
a peculiar quality or timbre, characterized as pulmonary or vesicu- 
lar ; pitch, and duration. Morbid deviations from healthy reson- 
ance are to be analyzed, and studied under the same general as- 
spects. It is by attention to these different qualities that the signs 
developed by percussion are recognized, and discriminated from each 
other. Abnormal sounds, then, we repeat, are distinguished from 



PERCUSSION IN DISEASE. 99 

healthy resonance, and from each other, by variations in intensity, 
in quality, in pitch, and in duration. 

Proceeding to a description of the physical signs of disease deve- 
loped by percussion, the question at once arises, what arrangements 
and what terms shall be adopted ? Authors differ upon this point. 
The following classification appears to me sufficiently comprehensive 
and minute for practical purposes. 

1. Exaggerated Vesicular Resonance. — The term clear is usually 
employed to express both normal and undue intensity of sonorous- 
ness. The term is confessedly inappropriate, inasmuch as, strictly, it 
expresses not intensity, but purity of sound; but the application is 
sanctioned by usage. Clearness of resonance, however, is an ex- 
pression equally applied to instances in which the character of sound 
is changed. To observe precision, therefore, it is necessary to qualify 
it as vesicular^ when the resonance retains the peculiar quality indi- 
cated by that title. It were better to dispense with the term and de- 
signate the sound proper to health as norinal resonance^ and a sound 
increased beyond the limits of health, but not essentially changed in 
other respects, as exaggerated vesicular resonance. This will be the 
designation of the first of the heads under which the physical signs 
furnished by percussion are to be distributed. 2. Diminished Vesi- 
cular Resonance. — Diminution of resonance, as a sign of disease, is 
usually called dulness. A dull percussion-sound generally differs 
from the normal resonance, at the same time, in quality, pitch, and 
duration. This will constitute the second division. 3. Absence of 
Resonance, commonly known as flatness. The type of this sound 
is that produced when the thigh is percussed. This will make a third 
I division. 4. Tympanitic Resonance. — Under this division I embrace 
all varieties of sonorousness in which the vesicular quality is wanting. 
It will include the varieties called by some tubular, amphoric, and the 
cracked metal sound {hruit de pot fele). Tympanitic resonance 
usually presents deviations from that of health not only in quality 
but in intensity, pitch, and duration. 

Of the foregoing divisions it is perceived that the three first are 
based on deviations in the intensity of sound, the names denoting dis- 
tinctions in this character and none other ; while the last division is 
founded on a change in the quality of sound. Deviations in pitch and 
duration of sound are important, but there is no necessity for consti- 
tuting separate divisions based thereon, since, with few if any excep- 
tions, they are always associated with changes in intensity or quality. 



100 PHYSICAL EXPLOEATIOX OF THE CHEST. 

It suffices, therefore, and simplifies the subject, to consider the charac- 
ters of morbid percussion-sounds which are derired from the attri- 
butes just named, viz., pitch and duration, as incidental to the several 
classes embraced in the above arrangement. It seems to me that all 
the sounds developed b j percussion in disease admit of being resolved 
into four divisions! according to this arrangement, considering varia- 
tions not expressed bv the terms of the classification in the light of 
incidental characters. Other classes, however, are mentioned by some 
authors : Skoda, for example, distinguishes certain sounds, as either 
empty or full. Bv these terms he intends to express certain dif- 
ferences conveyed to the ear by the character of sound as to the size 
of the space in which it is produced, or in other words, the extent of 
its difiusion. He illustrates the distinction thus : " We do not judge of 
the size of a resonant body by the strength of the sound which strikes 
upon the ear ; the slightest vibration of a large bell tells of its magni- 
tude ; the loudest ringing of a little bell misleads no one as to its small- 
ness ; neither do we judge of the dimensions of bodies, from the pitch 
of their sounds.'*'^ To make this the basis of a distinct class of sounds 
seems to me an over-refinement, tending to complicate the subject, and 
thereby discourage the student. The reahty of the distinction, how- 
ever, may be admitted, and differences in this respect considered, like 
diversities in pitch and duration, incidental to the sounds arranged in 
the several divisions that have been adopted. The terms fulness 
and emptiness are unfortunate, not expressing, except constructively, 
the meaning attached to them by the translator of Skoda's treatise ; 
but it would be difficult to fix on other terms which express the dis- 
tinction more satisfactorily. 

It remains to consider the phenomena falling under the foregoing 
classes severally, and their relations to the different morbid conditions 
of which they are the signs. 

1. ExaCtCtEEATed Vesiculae Resonance. — Increased resonance, 
the vehicular quality of sound being preserved, is chiefly important 
as a sign of a single morbid condition, viz., abnormal accumulation 
of air in the pulmonary cells, constituting pulmonary or vesicular 
emphysema. The physical change in the lung in this affection ren- 
ders the fact of an increased sonorousness sufficiently intelligible. 
The amount of resonance proper to health depends on the presence 
of air in a certain proportion to the solid parts. When, from disease, 

' Op. cit. ^ 



PERCUSSION IN DISEASE. 101 

the quantity of air is increased, the solid parts remaining the same, 
or even diminished by the atrophy which may accompany emphy- 
sema, a greater intensity of the percussion-sound would be looked 
for. Associated with signs developed by other methods of explora- 
tion, this is quite distinctive of emphysema. With the exaggerated 
resonance the vesicular quality is preserved. This fact distinguishes 
it from the increased sonorousness due to another and quite different 
affection, viz., pneumothorax, in which an abnormal clearness exists, 
without the vesicular quality, in other words with tympanitic reso- 
nance. In emphysematous distension of lung, however, the vesi- 
cular quality of resonance, although preserved, is more or less dimi- 
nished, and in proportion as it loses this quality it acquires a tympa- 
nitic character: this, a priori, would be expected. Moreover, the 
increase in sonorousness is not proportionate to the degree of enlarge- 
ment or distension of the air-cells. This interesting fact has been 
pointed out particularly by Skoda. If the lung become highly emphy- 
sematous, and the chest considerably expanded in consequence of the 
greater volume which the lung acquires, instead of being remarkably 
sonorous the chest may even yield on percussion a dull sound, and 
under these circumstances the vesicular quality is proportionally less 
marked. This fact is probably due mainly to the extreme tension of 
the pulmonary organs and the thoracic parietes. 

In proportion as exaggerated vesicular resonance preserves the 
vesicular quality, it may probably be stated as a general rule that 
the percussion-sound is long in duration and low in pitch. Con- 
versely in proportion as it loses this quality, and becomes tympanitic 
in character, it is shorter and higher in pitch. 

In determining the existence of exaggerated vesicular resonance 
we should be at a loss in cases in which both lungs are equally 
affected by emphysema, were we not aided by signs developed by 
other methods than percussion, and also by symptoms ; because we 
have no fixed standard of natural resonance, and there are wide dif- 
ferences in different persons in this particular. The evidence afforded 
by percussion alone is much more complete when the affection is 
limited to one side, or exists to a greater extent on one side than on 
the other, which is usually the case. Under these circumstances we 
have the advantage of a comparison of the two sides. It is needless 
to add that the natural resonance of different regions on the same 
side differing considerably in health, it is necessary here, as in other 
instances, to institute a comparison between corresponding situations 



102 PHYSICAL EXPLORATION OF THE CHEST. 

on the two sides. In one situation, however, the effect of emphysema 
is to render more equal corresponding regions in which there is a 
disparity in health ; reference is had to the mammary region. The 
prsecordia is naturally dull in consequence of the presence of the 
heart, which the lung does not completely overlay. But if the left 
lung become highly emphysematous, the heart is fully covered and 
removed from the thoracic walls, so that the percussion-sound is 
abnormally clear in that situation, and it may require forcible per- 
cussion to discover a disparity between the two sides. 

Guided by percussion, alone, in cases in which the vesicular reso- 
nance is greater on one side than on the other, there would be a 
liability to err in attributing this apparently increased sonorousness 
to emphysema, when, in fact, it is simply the normal resonance, but 
relatively greater in consequence of disease seated in the other side, 
which diminishes the resonance on that side. This error is avoided 
by resorting to other signs pointing to the side affected. 

As already stated, exaggerated vesicular resonance is chiefly valu- 
able as a sign of emphysema. It is altogether probable that when 
the lung of one side becomes hypertrophied, in other words, acquires 
an increased expansion in consequence of the lung on the other side 
being rendered useless by disease, as in cases of chronic pleurisy, the 
degree of resonance exceeds that belonging to health. It is difficult 
to determine this fact positively, unless we chance to know the 
amount of resonance peculiar to the individual before he was attacked 
with the disease, because we lose the resonance of the diseased side 
as a standard for comparison. The point, however, possesses little 
or no importance in diagnosis. 

The sonorousness of the chest, becomes, of course, greater in pro- 
portion as the coverings of the thoracic walls are attenuated in the 
progress of diseases attended by emaciation. But under these cir- 
cumstances both sides are equally affected ; this, in connection with 
the absence of other signs, suffices to exclude pulmonary disease. 

2. Diminished Resonance, or Dulness. — As a sign of disease 
resonance is much oftener lessened than augmented. Indeed, this is 
the change which occurs in the vast majority of pulmonary affections. 
The morbid conditions which occasion it are quite numerous. Under 
this division, it should be premised, are embraced the instances in 
which the resonance is less than normal, without being completely abo- 
lished, and the diminution may have every possible degree of gradation 



PEHCUSSION IN DISEASE. 103 

from the sonorousness of health, to a point at which resonance ceases. 
The sound is dull until this point is reached, when it becomes ^a^. 

Normal resonance is impaired, whenever, from any morbid cause, 
solids or liquids occupy space within the chest at the expense of the 
normal quantity of air in the vesicles. This occurs in a variety of 
diseases, the more important of which are as follows : 

a. In some rare instances a disproportion between the solid struc- 
tures and the air takes place as the result of the reduction in the quan- 
tity of the latter, the former not being increased. An obstruction may 
exist from the presence of a morbid product or a foreign body within 
the bronchial tubes, which resists the ingress of air to the cells with 
inspiration, but permits its egress with expiration. Collapse of more 
or less of the pulmonary lobules, under these circumstances, may 
follow. The effect on the percussion-sound is to diminish the normal 
resonance, which depends, cceteris paribus, on the quantity of air con- 
tained in the pulmonary vesicles. In the vast majority of cases, 
however, this effect is due to the increase of the solid contents of the 
chest, which occupy space to the exclusion of air. 

h. A thin stratum of liquid between the pleural surfaces, serum, or 
serum and coagulable lymph, in hydrothorax and pleurisy, may 
occasion more or less dulness on percussion. This is an infrequent 
cause, the quantity of liquid effusion and fibrinous exudation gene- 
rally being so disposed, and in sufficient quantity, to occasion total 
loss of resonance, or flatness, over a greater or less distance from 
the base of the chest upward. Instances, however, may occur, 
in which, from adhesions of the pleural surfaces, a small quantity of 
these products may be confined within circumscribed limits, removing 
the lungs from the walls of the chest sufficiently to diminish but not 
destroy vesicular resonance. 

In cases in which a considerable quantity of liquid is contained 
within the pleural sac, the lung, of necessity, undergoes compression 
and condensation. Over the portion of the chest beneath which the 
condensed lung lies, the vesicular resonance is diminished, the reduc- 
tion of the lung in volume increasing the proportion of solids to the 
quantity of air within the cells. At the summit of the chest, there- 
fore, the percussion-sound is usually dull. But under these circum- 
stances a sonorousness frequently exists, modified in quality, which 
will be noticed under the head of Tympanitic Resonance. 

c. A very large accumulation of morbid products within the bron- 
chial tubes may be attended by slight dulness. This also is ex- 
tremely rare. Unless the quantity be so great as not only to fill the 



104 PHYSICAL EXPLORATION OF THE CHEST. 

tubes, but to distend them, and thus encroach upon the air-cells, the 
resonance on percussion is not appreciably lessened ; hence, as will be 
seen hereafter, in cases of bronchitis attended with very abundant 
expectoration, the normal resonance is not sensibly impaired. Skoda 
denies that appreciable dulness ever exists in cases of bronchitis. 
This assertion is too positive, and does not accord with the observa- 
tions of others. 

d. Congestion of the pulmonary vessels may exist to such an ex- 
tent that the blood, occupying space at the expense of the normal 
capacity of the air-cells, the resonance is diminished. Moderate or 
even considerable congestion does not produce this effect. The 
engorgement must be great ; a sufficient degree obtains in some cases at 
least of pneumonitis, during the first stage, or stage of engorgement,^ 
and in the hypostatic congestion of the dependent portion of the 
lungs taking place towards the close of life in various diseases. 

e. The exudation of coagulable lymph within the air-cells which 
characterizes the second stage of pneumonitis, or the stage of solidifi- 
cation, occasions notable dulness. Here the cells themselves are 
to a greater or less extent filled with solid matter, supplanting, in 
proportion to its abundance, the air. The dulness will, coeteris 
paribus^ be proportionate to the quantity of exudation, occasionally 
merging into complete flatness. Certain circumstances distinctive of 
the solidification of the lung, which occurs in the form of pneumonitis 
usually presented in the adult, viz., lobar pneumonitis, will be 
noticed under the head of Absence of Kesonance or Dulness. 

/. Effusion of serum within the air-vesicles and areolar tissue of 
the lungs, is another morbid condition attended by dulness, and in 
some instances flatness. This condition, never a primitive affection, 
but generally incident, when it takes place, to disease of heart induc- 
ing pulmonary congestion, is to be included among the infrequent 
causes of diminished resonance. 

g. Deposit of tuberculous matter within the cells is the most fre- 

^ This appears to be denied by Skoda ; and since death rarely occurs from pneumonitis 
during the stage of engorgement, opportunities to demonstrate the correctness of the 
statement which has been made are not often obtained. In a case under my observation, 
in which a patient died with enormous dilatation of the heart shortly after an attack of 
pneumonitis, the limits of the lower lobe of the right lung had been marked on the 
chest by a line of obvious dulness on percussion ; and this lobe after death was found 
in the first stage of inflammation, no solid exudation having taken place. (Hospital 
Record for April, 1855, cases of Peterson.) The denial by Skoda is not in accordance 
with the observations of others. 



PERCUSSION IN DISEASE. 105 

quentin its occurrence of the morbid conditions characterized by the 
change in the percussion-sound under consideration. The mode in 
which it occasions diminished resonance is the same as in pneumonitis. 

h. Carcinomatous infiltration of the pulmonary parenchyma, for- 
tunately extremely rare, will occasion dulness, in the same manner 
as tuberculous matter. 

i. Extravasation of blood, constituting pulmonary apoplexy, is 
another rare form of disease, producing the same effect in the same 
way. 

k. Tumors, morbid growths, aneurisms, and enlarged bronchial 
glands, are occasional forms of disease, which, according to the extent 
of encroachment on the thoracic space, lead either to diminution or 
absence of vesicular resonance. 

In each and all of these various affections, percussion alone deve- 
lopes nothing beyond the simple fact of the existence of some physical 
alteration preceding dulness. It affords no information in parti- 
cular cases, as to which one of the different morbid conditions exists. 
To determine this point the co-operation of other methods of explora- 
tion is requisite, taken in connection with symptoms, and the known 
laws of diseases. In certain instances, however, the situation of the 
dulness, irrespective of other signs, or of symptoms, is a sufficient 
ground for a strong presumption as to the nature of the disease. If 
the dulness extend over the space occupied by the lower lobe, espe- 
cially of the right lung, it probably arises from pneumonitis, this 
affection being seated, in the great majority of cases, in the lower 
lobe, oftener of the right than the left side. If, on the other hand, 
the dulness exists at the summit of the chest on one side, the chances 
are greatly in favor of its proceeding from a tuberculous deposit, in 
view of the frequency of that disease, taken in connection with the 
fact that the deposit first takes place, almost invariably, at or near 
the apex of the lung on one side. But it is rarely, if ever, necessary 
to rely on the evidence afforded by one only of the methods of explo- 
ration, or to depend on signs to the exclusion of symptoms. And it 
is one of the great advantages pertaining to physical diagnosis that 
phenomena developed by different modes of examination may be 
brought together, mutually serving to supply deficiencies, correct 
liabilities to error, and combining to render positive the conclusions 
therefrom educed. 

Incidental to diminished vesicular resonance are certain deviations 
relating to pitch, duration of sound, and the sense of resistance. As 



106 PHYSICAL EXPLORATION OP THE CHEST. 

a general rule, when the solid contents of the chest are increased at 
the expense of aii' vriihin the cells, whatever may be the form of dis- 
ease involving this physical change.not only is the vesicular resonance 
diminished, but the pitch of the percussion-sound is raised, the sound 
is shortened in dui'ation, and the sense of resistance is increased. 
These four deviations generally go together, viz., diminished resonance, 
elevation of pitch, shortened duration, and greater resistance. This rule 
is important to be borne in mind in the practice of percussion. A dull 
vesicular sound, contrasted vrith a clear vesicular sound, is at the 
same time higher in pitch, less in duration, and the sense of resis- 
tance is greater. In the several forms of disease, therefore, which t 
have been enumerated, these changes are united. 

A point highly important to be understood in connection with this 
subject is, that vesicular resonance may be diminished or abolished, 
not involving a corresponding loss, but even with an increased degree ^ 
of sonorousness : that is, sonorousness may exist to an extent equal 
to that in health and even greater, but without the vesicular quality, 
the resonance, in other words, being more or less tympanitic. In the 
majority of instances in which the solid contents of the chest are 
increased at the expense of the air in the vesicles, it is probably true 
that the percussion-sound becomes proportionately dull in every sensej 
using this term with its ordinary acceptation ; but in a certain ratio of f 
cases it is otherwise. The vesicular resonance is diminished, but in 
this sense only the sound is dull. The vesicular quality is replaced 
by a sonorousness, it may be exceeding the normal intensity, and I 
approximating more or less to a tympanitic resonance. Hence, in 
cases of compression of lung from pleuritic effusion, as already stated, ^ 
and also in solidification from tuberculous deposit or inflammatory pro- 
ducts, percussion sometimes ehcits an exaggerated tympanitic sound. 
This point will be considered under the head of Tympanitic Eesonance. 
The fact just stated obviously has an important bearing on the sub- 
ject under present consideration. The proportion of instances of the 
forms of disease just referred to, in which the fact exists, remains to 
be settled by numerical observations. 

Diminished vesicular resonance, with or without tympanitic sonor- 
ousness, in the different forms of disease thus characterized, is ascer- 
tained by contrasting the two sides of the chest ; for fortunately the 
laws governing pulmonary affections do not conflict with making one 
side a standard of comparison by which to estimate the deviations from 
health on the other side. "With very few exceptions, in cases of pulmo- 



PERCUSSION IN DISEASE. 107 

nary diseases, attended by alterations in the healthy resonance on 
percussion, either the affection is confined to one side, or is more ad- 
vanced on one side than on the other. This would almost seem to be 
an express provision for facility of diagnosis. In by far the greater 
proportion of cases occurring in practice, in which the resonance onv 
one side is diminished from a morbid cause, the fact is determined 
without difficulty. The disparity between corresponding points on 
the two sides is sufficiently obvious to be easily recognized. Occa- 
sionally, a delicate comparison is necessary. This is sometimes the 
case in the early stage of phthisis, when the morbid deposit is in the 
form of small disseminated tubercles. To appreciate a slight dif- 
ference which may be significant of the small physical change, that 
has as yet taken place, observing all the precautions that have been 
pointed out, and repeating on corresponding points at the summit of 
the chest, a succession of strokes as equal in every respect as possible, 
the sound elicited on the two sides is to be compared as respects in- 
tensity, vesicular quality, pitch, and duration. My observations have 
led me to regard attention to pitch, as particularly useful, in cases in 
which delicacy of discrimination is required.-^ A variation in pitch 
by one who has what is called a " musical ear," is more easily recog- 
nized, than a slight disparity in the amount of resonance ; and in 
some instances the former may be distinguishable without difficulty, 
when the latter is inappreciable. In cases, therefore, of suspected 
tuberculosis, it is important to compare the sounds on the two sides as 
if they were musical notes, in order to determine whether they are in 
unison, or differ in their diatonic relation to each other. A difference 
in pitch may then be the only discoverable evidence of dissimilarity, 
and, in connection with other signs and symptoms, may be entitled to 
considerable weight in the diagnosis.^ The importance of attention to 
the pitch of percussion-sounds with a view to greater nicety and accu- 
racy of discrimination, seems to me not to have been sufficiently appre- 
ciated by most writers on the subject of physical exploration. A 
late writer, indeed, whose views have attracted much attention, de- 
clares that variations in this respect are of little value in practice.^ 
It is worthy of remark, that in the classification of percussion-sounds 
by Auenbrugger, variations in this respect occupied the first rank, 

' See Prize Essay by author. 

^ This is probably true Of the exceptional cases, to be referred to again under another 
head, in which the percussion-sound over the site of tubercles has a greater degree of 
sonorousness than belongs to health. See under head of Tympanitic Resonance. 

« Skoda. 



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PERCUSSION IN DISEASE. 109 

of percussion is the same as when the thigh is struck. The sound 
is said to be flat. Perfect flatness on percussion obtains especially 
when the pleural sac is filled with liquid effusion, either serum, serum 
and lymph, or pus. If the lung or an entire lobe be completely 
solidified by the exudation of lymph, or infiltrated tuberculous mat- 
ter, there may be flatness, but it is rarely the case that sonorousness 
is so completely extinct as in the former instance. The presence of a 
small quantity of air in the bronchial tubes, and the proximity of the 
soHdified portion (if the whole lung be not solidified) to another por- 
tion in which the vesicles contain air, occasion a slight degree of re- 
sonance, although perhaps so extremely slight as not to be appreciable 
without comparison with the efi'ect of percussion on a part which is 
absolutely flat. A large tumor within the chest may occasion flatness. 
In cases in which flatness, or a degree of dulness closely approxi- 
mating thereto, exists over a portion of the chest, the discrimination 
lies between liquid efiusion, solidification of- lung, and morbid growth. 
It follows from the statement just made, that the degree of flatness, 
or, more correctly, the existence or not of positive flatness, as distin- 
guished from dulness, enters into this discrimination. Displacement 
of the lung by the accumulation of liquid, or a solid tumor, may occa- 
sion absence of all resonance, while over lung, be it ever so com- 
pletely solidified, there is usually only an extreme of dulness. But 
in making this discrimination, important information is derived from 
the situation of the flatness, and, in certain cases, the effect of varia- 
tions in the position of the patient. If the flatness be situated at 
the superior portion of the chest, the probabilities are vastly 
opposed to its being due to the presence of liquid, for, excepting in 
some instances, which must be exceedingly rare, in which liquid efiu- 
sion is confined to the upper part by adhesion of the pleural surfaces 
below, it will fall to the bottom of the sac, and the flatness will extend 
upward for a distance proportionate to the amount of the efiusion. The 
extreme dulness, or possibly absolute flatness, due to solidification of 
the lower lobe in pneumonitis, may be ascertained by delineating on 
the chest its upper boundary, and finding that the line pursues the 
direction of the interlobar fissure. This is a point pertaining to the 
physical diagnosis of pneumonitis, to which writers on the subject 
have not sufficiently adverted. Moreover, the limits of the flatness 
or dulness incident to that disease, remains unaltered in every posi- 
tion of the patient. The same remark will apply to tumors, unless, 
as may happen, and an instance is given by Walshe, they are not 



110 PHYSICAL ZXPLORATIOIff OF THK CHEST. 

attached except by a small pedicle. But in a certain propDrtion of 
eases in vMcli Kqnid is contained idtlun the pleural sac, the lerel of 
the snrface of the liquid yaries with different positions of the hodj, ' 
and may he ascertained withont drfficnlty by percussion. If the 
lerel be ascertained by determimng the line of flatness, and marked 
on the chest when the body of the patient is in an upright position, 
it win be foimd to encircle the chest nearly in a horizontal direc- ^ 
tion, the liqmd obeying the same law of gravity within the chest, as ' 
if it were contained in a Tessel out of the body. If now the patient 
take a recumbent posture, the lerel of the liquid in front wiLL be 
found to hare descendedy and a line denoting the upper boimdary of 
the flatness, pursues from this point a diagonal direction intersecting 
obliquely the horizontal line previously made. Or, without taking 
pains to demonstrate the Tariation of level so elaborately, which is 
not always convenient in practice ; let the upper limit of the flatness 
in £ront be ascertained by percussion, while the trunk is in. a vertical 
portion; then cause the patient to lie down, and ascertain if the 
resonance do not extend an inch or more below the poiQt at which, 
in the previous portion, the upper limit of flatness was found to exist- 
A few ounces of fluid in the pleural cavity may, in some instances, be [ 
detected in the manner jnst described. The physical explanation of 
tiiese changes is sufficiently obvious. This mode of determining, by 
pereu^cm, tiie presence of liquid is not applicable to all c-ases, but 
onbf to those in which the quantity is not so great as to fill the pleu- 
ral sac, compressing the lung into a small space, and to those in which ' 
the movement of the liquid is not prevented by adhesions of the ' 
pleural sur&ces. Both these conditions are apt to be wanting in 
pleurisy, and hence the test is less frequently available in that affec- 
tioa than in hydrothorax. The discrimination, however, of flatness 
occasioned by liquid effusion, from that which may be due to soli<iifi- 
cation of lung, does not depend exclusively on the evidence obtained 
by percnsdon. The phjfmeal signs derived from other methods of 
exploration, combined with those afforded by percussion, generally 
warrant a positive diagnosis. The employment of percussion after 
the rules just given enables the practitioner to determine from day to 
day, or from week to week, the changes which take place in the quan- 
tity of liquid effusion. The progress of the disease and the effects of 
remedies may thus be accurately observed. This is a practical con- 
sideration of no small importance. With a view to note the increase 
or diminution of the fluid, the line of flatness, denoting the level of 



PERCUSSION IN DISEASE. Ill 

the liquid, while the body is in a vertical position, may be perma- 
nently marked on the chest by means of a stick of the nitrate of 
silver. The series of lines thus made during the course of pleurisy 
or hydrothorax, form a kind of diagram illustrating its past history. 
The physical conditions producing absence of resonance, or flatness, 
occasion at the same time, and usually in a notable degree, a sense 
of increased resistance ; in other words, the ribs are less yielding to 
pressure from without. This sign, cceteris paribus, will be marked in 
proportion to the elasticity of the costal cartilages, and hence be more 
obvious in early life than after the thoracic walls become unyielding 
from the stiffening and ossification incident to advanced years. 

4. Tympanitic Kesonance. — Agreeably to the definition already 
given, under this head are embraced all kinds of sonorousness which 
want the special quality or timbre characteristic of the presence of air 
in cells, which has been distinguished as vesicular resonance. The 
name implies a drum-like sound, and the type is the sound emitted by 
the tympanitic abdomen. It is proper to state that the expression is 
not generally used in a sense so comprehensive. By some writers^ it is 
limited to exaggerated pulmonary or vesicular resonance. With the 
French it is considered to denote a clear, intense sound, without 
necessarily having any special quality or timbre.^ It seems appro- 
priate, and simplifies the subject, to call the different percussion-sounds 
tympanitic, which, however they may differ among themselves, agree 
in this, viz., that they are non-vesicular. The distinctive feature, 
then, of tympanitic resonance pertains to its quality or timbre. It 
may have any degree of intensity so long as it possesses the negative 
distmction just named. It may be louder or clearer than the normal 
resonance, or, on the other hand, a sound ever so dull, which is not 
flat, may be tympanitic.^ It presents under different circumstances 
striking modifications, which are practically not unimportant, but it 
suffices to consider them as constituting different varieties of tympa- 
nitic resonance. 

* Walshe, first edition. 

2 Dr. Henri Roger, Archives g^nerales de m^decine, 1852. 

' Dr. Stokes makes a statement similar to this. Speaking of the difference between 
the resonance on the left side from the presence of gas in the stomach and that from 
pneumothorax, he says, " I might say, and stethoscopists will appreciate the distinction, 
that the one is a tympanitic dulness, the other a tympanitic clearness." Diseases of the 
Chest, 2d Am. edition, 1844, page 284. 



112 



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PERCUSSION IN DISEASE. 113 

within tlie pleural sac. This physical condition characterizes the dis- 
ease called pneumothorax^ or as air and liquid are usually combined 
in variable proportions, pneumo-liydrotJiorax. In this affection per- 
cussion of those portions of chest situated over the space occupied 
by air, elicits a loud sonorousness totally devoid of vesicular quality 
and which gives to the mind an impression of a hollow space of con- 
siderable size filled with air. So far as an idea of size is conveyed, 
it is what Skoda calls a full, in distinction from an empty sound. 
An interesting fact pertaining to the sound occurring as a sign of 
pneumo-hydrothorax has been pointed out by the author just named. 
When the chest is greatly distended by the large accumulation of 
liquid and air, the degree of sonorousness is less than when the 
distension is but moderate. The sound may even become dull. It 
is stated by Skoda that it becomes non-tympanitic. It is not, how- 
ever, to be understood by this expression that it acquires the vesi- 
cular quality of resonance, although the normal resonance of the 
chest is cited by Skoda as the type of a non-tympanitic sound. It 
is evident that the quality of resonance must remain tympanitic 
under these circumstances. It is meant only that it loses its inten- 
sity. This fact is probably due to the extreme tension of the tho- 
racic walls. A similar phenomenon, as remarked by Walshe, is 
observed in a drum. " If a drum be tightened to the extreme point 
possible, and all escape of air from its cavity prevented, its sound, 
when struck, becomes muffled, toneless, almost null." 

The tympanitic resonance in pneumo-hydrothorax sometimes has 
a ringing metallic tone, resembling the sound produced by tapping 
lightly the back of the hand when the palm is applied firmly over the 
ear. This character of resonance is more apparent if percussion be 
made while the ear is applied to the chest. 

The presence of liquid effusion in cases of pneumo-hydrothorax, 
gives rise to flatness on percussion below the inferior boundary of tym- 
panitic resonance, and the relative portions of the surface of the chest 
over which resonance or flatness are found, will serve to determine 
the relative quantities of liquid and air. If the pleural surfaces are 
free from adhesions, the tympanitic resonance will, of course, exist at 
the superior portion of the chest, the body being in a vertical position. 
But inasmuch as pneumo-hydrothorax occurs oftener as an accidental 
complication of phthisis than otherwise, and since, in the latter affec- 
tion adhesions generally take place to a greater or less extent, the air 
may be prevented from distending the upper part of the pleural sac. 

8 



114 PHYSICAL EXPLORATION OF THE CHEST. 

Under these circumstances, there may be a liability of attributing the 
tympanitic sonorousness due to air between the pleural surfaces, to 
the presence of gas within the stomach. The situation of the space 
occupied by air will be found to vary with the position of the patient. 
Thus, if when the trunk is inclined far backward the dimensions of the 
surface corresponding to the tympanitic resonance be marked on the 
chest in front, they will be considerably lessened by repeating the 
examination when the trunk is inclined far forward. The same is 
true, of course, of the posterior surface. The level of the surface of 
the liquid may be ascertained as in ordinary pleurisy, or in hydro- 
thorax, and this will be found to vary with different attitudes, obeying 
the same rules as in the diseases just named. 

The diagnosis of pneumo-hydrothorax does not rest exclusively on 
percussion, although the evidence afforded by this method is gene- 
rally in itself quite conclusive. With an imperfect knowledge of the 
subject, however, there are liabilities to deception. Emphysema, as 
has been seen, is attended not only by exaggerated sonorousness, but 
a quality of resonance approximating to the tympanitic. It does not, 
however, lose entirely the vesicular quality. It is unaccompanied 
by the physical signs of liquid effusion, and is distinguished by signs 
obtained by other methods. The whole of the left side is sometimes 
rendered highly tympanitic by distension of the stomach with gas. 
In such instances, aside from the distinctive circumstances which are 
not less applicable than in emphysema, the intensity of the tym- 
panitic resonance is greatest at the lower part of the chest; and 
diminishes in proportion as percussion is made toward the summit, thus 
reversing the rule which obtains in pneumo-hydrothorax. 

A condition more likely to lead into error is ordinary pleurisy, at- 
tended, as is not unfrequently the case, by a tympanitic resonance, 
more or less strongly marked, above the level of the liquid, on the 
surface beneath which is situated the compressed lung. For the 
knowledge of this important as well as interesting fact, to which allu- 
sion has already been made, we are mainly indebted to Skoda. 
He is entitled to the credit of having pointed out the frequent occur- 
rence of increased and tympanitic sonorousness over the chest, above 
the line of flatness denoting the height to which the liquid rises. 

This subject has also been investigated by Dr. Henri Roger of 
Paris. ^ The latter observer found, that of 51 cases of pleurisy,- 41 
were characterized by this feature. In these cases the increased tym- 

• Archives Generales de M^decine, 1852. 



PERCUSSION IN DISEASE. 115 

panitic resonance was not constantly present, but existed for a greater 
or less period during the progress of the disease. The fact of the 
occurrence of this feature was not altogether novel. It had been 
observed by Dr. Williams. I had noted it as present, in a marked 
degree, in two cases of chronic pleurisy which came under my ob- 
servation several years ago.-^ In the discovery of its occurrence in 
a large majority of cases consists the novelty of the point under 
consideration. This being the fact, it seems surprising that it should 
have been so long overlooked. 

An explanation, oifered by Dr. Roger, of the frequency of its oc- 
currence having escaped attention, is that practitioners after making 
the diagnosis of the presence of liquid effusion, have not been in the 
habit of comparing the two sides of the chest, above the level of 
the fluid. According to Dr. Roger, the most favorable condition for 
the sign, is when the quantity of effusion is sufficient to fill a third or 
half the cavity of the chest, and it does not exist when the quantity is 
either very small or very large. Dr. Aran, however, has observed 
it in the early stage of pleurisy, in which the amount^ of effusion was 
quite small. The rationale of the sign is a matter open for discus- 
sion. The few remarks pertaining thereto that I shall offer, I will defer 
till other conditions also characterized by tympanitic resonance have 
been noticed. 

Exaggerated and tympanitic resonance exists sometimes over the 
lower lobes when solidified in pneumonitis. The credit of having 
first called attention to this fact, is attributed to the late Dr. Graves, 
of Dublin. On the left side this is not uncommon, and the explana- 
tion which at once suggests itself, and Avhich is probably applicable 
to many instances, refers the resonance to the transmitted gastric 
sound so frequently found in health at the inferior portion of the left 
side. On the right side it may be due to the presence of gas in the 
transverse colon. 

An exaggerated and tympanitic resonance over the superior lobes 
in cases of pneumonitis in which the lower lobes are solidified, is not 
unusual. This has been noticed by several observers. Judging from 
the results of recent observations directed to this point, I should 
say this was the rule. This, then, is to be classed among the different 
morbid conditions in connection with which increased sonorousness 
with the tympanitic quality is produced, if not uniformly, yet in a cer- 
tain proportion of cases. 

' See Essay on Chronic Pleurisy, by author. 

* Note to French translation of Skoda's Treatise. 



116 PHYSICAL EXPLORATION OF THE CHEST. 

Belonging to the same category is the occurrence of tympanitic 
resonance occasionally, more or less intense, over consolidation of the 
superior portion of the lung from pneumonitis or tuberculosis. This 
I have repeatedly observed. Skoda has also demonstrated the 
co-existence of tympanitic resonance with oedema and pulmonary 
apoplexy, and Dr. Roger has observed it in lobular pneumonia.'' 

These developments, in a great measure of recent date, are of con- 
siderable importance in their practical bearing on physical explora- 
tion. A sonorousness greater than natural and tympanitic in quality, 
may be present in connection with physical conditions of the parts 
within the thorax, which a jynoi'i would not be expected to give 
rise to such an effect, and which, in fact, often, if not generally, are 
accompanied by dulness or flatness. Whether or not we may be able 
to account for the facts which have been stated, they are established 
by clinical observation. Irrespective, therefore, of theoretical views 
relative to their rationale, the facts are to be borne in mind. To 
repeat them, in general terms, — in cases of pleui'isy with effusion, or 
hydrothorax, the resonance above the level of the liquid is frequently 
more intense than on a corresponding situation on the non-affected 
side, and tympanitic in quality ; in cases of pneumonitis affecting an 
inferior lobe, the healthy lung above the limits of respiration generally 
emits a resonance more or less intense and tympanitic ; and over soli- 
dified lung, not only when the lower lobe is the portion affected, in 
which case we may suppose a gastric or intestinal sound is transmitted, 
but also when the solidification is situated in a superior part, be it from | 
tubercle, from extravasated blood, or lobular pneumonitis, an exagge- ! 
rated and tympanitic resonance may exist over the situation of the 
solidified portions. 

Without attention to these facts, the greater sonorousness on one 
side existing in connection with the several morbid conditions just 
mentioned, might possibly lead the observer to conclude that th6 
healthy side, from its being relatively dull on percussion, was the 
side diseased, the morbid resonance being taken as the standard of 
health in the individual examined. M. Roger states that he has 
known of instances in which this mistake was committed. Especially 
in the diagnosis of early tuberculous disease, it is important to recol- 
lect that an exaggerated tympanitic resonance at the summit of the 
chest may attend the presence of tubercles. Such instances are excep- 
tions to the general rule, stated under another head, that a tubercu- 
lous deposit occasions diminished resonance on percussion. 

' Dr. Roger, in Archives generales de Medecine, 1852. 

1 



PEKCUSSION IN DISEASE. 117 

The rationale of the foregoing interesting and important facts is 
a matter at present suh judice, and inasmuch as I have no fruits of 
personal experiments or researches to offer, I shall not engage in a 
lengthened discussion of the subject. To account for an exaggerated 
tympanitic resonance under circumstances in which it is clinically 
exceptional, and apparently opposed to the laws of physics, viz., when 
the lung is compressed by the presence of liquid, or rendered more 
dense than natural by solidification, the doctrine has been advanced 
by Skoda that *' if the lung contains less than its normal quantity of 
air, it yields a sound which approaches to the tympanitic, or is dis- 
tinctly tympanitic."^ He bases this doctrine on experiments made 
upon the pulmonary organs in the dead subject, and also removed from 
the body, taken in connection with the facts pertaining to disease which 
have been presented. Clinically this doctrine cannot be considered 
to hold good in the light of a general law for abnormal sonorousness 
in cases in which the lungs are to a greater or less extent deprived 
of their normal quantity of air, in other words rendered more dense 
by disease, is by no means an invariable sign, but, on the contrary, 
occurs only as an exception to the general rule. The sign, there- 
fore, cannot be due simply to the mere deprivation of air, or any 
constant condition, but to some contingent circumstances. The 
question, then, is, what are these contingent circumstances ? In 
cases of effusion within the pleura, the natural effect is to condense 
the lung by compression of the liquid ; but it is not certain that in 
all instances the proportion of air to the solid tissues above the level 
of the fluid is diminished. By the force of the inspiratory movements 
causing greater dilatation of the cells, the ratio of air may perhaps 
even exceed the limits of health. It is not improbable that the origin 
of the emphysema and dilatation of the bronchise which sometimes suc- 
ceed pleurisy may have a date anterior to the absorption of the effused 
liquid. These are points which claim investigation. 

But in cases in which abnormal sonorousness at the summit of the 
chest occurs in connection with solidification of the lower lobe from 
pneumonitis it is gratuitous to suppose that the relative quantity of 
air to solid tissues in the upper lobe is diminished. Its occurrence 
under these circumstances is evidence against the necessity of dimi- 
nution of air in other instances. Dr. Boger found by experiments 
that the sound elicited by percussing a lung removed from the body 
is modified according to the substance on which it rests. Thus on 

^ Markham's translation, Am. edition, page 47, 



118 PHYSICAL EXPLORATION OP THE CHEST. 

a bed of muscle or bone it emitted a normal sound, but floating on 
the surface of a liquid it yielded a tympanitic sound. This fact may 
be applied to explain the abnormal resonance incident to pleuritic 
effusion, but not to that found to exist in certain instances over the 
healthy lung in cases of pneumonia.* 

The tympanitic resonance, more or less intense, which is observed 
over solidified lung at the inferior portion of the chest, especially 
on the left side, admits of an explanation already stated, viz., trans- 
mitted sonorousness from the stomach and intestines. When it is pre- 
sented at or near the summit of the chest, over deposits of tubercle or 
extravasated blood ; or in cases of pneumonitis affecting the upper lobe, 
some other explanation is requisite. It has been attributed to two 
incidental circumstances, viz. : 1. The air in the trachea and large 
bronchial tubes, in consequence of surrounding solidification, may be 
supposed to give rise to a resonance more or less intense, and of 
course devoid of the vesicular quality, in other words tympanitic, 
resembling the sound produced by percussing the trachea : this is the 
explanation offered by Dr. Williams.^ According to Skoda, direct 
experiments prove its incorrectness. He does not give an account 
of the experiments to which he refers ; and deductions from experi- 
ments made out of the body, applied to the parts in situ, are to be 
received with a certain amount of distrust. The explanation is 
adopted by so high an authority as Dr. Walshe on subjects pertaining 
to physical exploration, and it is considered by him adequate in part 
to explain the tympanitic sonorousness^ which is found at the sum- 
mit of the chest in cases of pleuritic effusion. An interesting case 
reported by M. Monneret, of Paris,^ goes to show, that in some in- 
stances, at least, of the latter description, this explanation may be valid. 
In this case, a patient at the Hospital Necker, in connection with the 
physical evidence of liquid in the chest, the percussion-sound at the 
summit, behind and in front, was persistingly tympanitic and at the 
same time dull. Paracentesis was resorted to, and a certain quantity 

^ I have observed in a case of pneumonitis affecting the lower lobe of the right lung, 
the physical signs of well-marked moderate emphysema limited to the upper lobe on the 
affected side, viz., tympanitic resonance, diminished intensity of the respiratory murmur, 
and increased convexity in the infra-clavicular region. Is not this significant of the 
condition giving rise to tympanitic resonance at the superior part of the chest on the 
affected side, both in cases of pleurisy and pneumonitis ? 

2 Lectures on Diseases of the Chest. Dr. Walshe attributes the suggestion to Dr. Hudson. 

3 Called by Dr. Walshe tubular. 

^ Gazette des Hopitaux, August 31, 1854. 



PERCUSSION IN DISEASE. 119 

of pus removed. Subsequently there took place perforation of the 
lung from the pleural surface within. After death, it was found that 
exactly within the limits of the tympanitic percussion-sound at the 
summit of the chest, the lung was firmly attached by old adhesions. 
The reporter attributes the tympanitic resonance in this case to the 
air within the bronchial tubes modifying the sound in consequence of 
the close attachment of the lung to the walls of the chest. 

2. The second incidental circumstance referred to is emphysema- 
tous dilatation of the cells in the vicinity of the solidified portions of 
lung. It is sufficiently intelligible that a tympanitic resonance should 
exist under these circumstances ; and this is admitted by Skoda. That 
the air-cells surrounding portions of lung rendered solid by tuber- 
culous deposits, or other forms of disease, are consequently liable 
to become emphysematous, is an admitted fact in pathology, and 
accords with the ingenious theory of the mechanism by which emphy- 
sema is produced, lately advanced by Dr. Gairdner of Edinburgh.^ 

It is readily conceivable that the two circumstances just stated, 
viz., the air contained in the bronchial tubes giving rise to resonance 
in consequence of solidification of the parts lying between these tubes 
and the walls of the chest, and local emphysema, may be combined 
contributing conjointly to render the percussion sound more or less 
intense and tympanitic. 

Thus far the expression tympanitic resonance has been considered 
in a generic sense, as a non-vesicular sound, difi'ering in difi'erent in- 
stances only in intensity. It is occasionally presented with peculiar 
modifications of quality, which are in some measure significant of a 
special pathological condition. These modifications may be embraced 
in two classes, viz., amplioric resonance, and the cracked-metal sound 
{bruit de potfele). 

Amphoric resonance denotes a metallic ringing sound, such as is 
sometimes elicited by percussing over the stomach, and which may 
be imitated by striking the cheek when the jaws are moderately 
separated and the integument rendered somewhat tense, as is done in 

' The second explanation will hardly apply to cases in which the entire upper lobe 
is solidified in pneumonitis, and under these circumstances I have repeatedly noted the 
presence of tympanitic percussion-resonance. There seems in such cases to be no alter- 
native but to adopt the explanation of Dr. Williams. That the tympanitic resonance in 
such instances is not transmitted from the stomach (on the left side) is probably proved 
by this fact, which I have repeatedly noted, viz., the pitch of the tympanitic sound at 
the summit, and that of the gastric tympanitic sound at the lower part of the chest, may 
present a marked disparity. 



120 PHYSICAL EXPLOKATIOX OF THE CHEST. 

the trick of imitating the pouring of liquid from a hottle. The per- 
cussion-sound occasionally assumes this peculiar intonation in pneumo- 
hydrothorax ; and possibly also in cases of solidification from inflam- 
mation or tuberculous deposit. But in the vast proportion of the 
instances in which it occurs it is occasioned by a tuberculous excava- 
tion of considerable size, and, of course, more or less empty. Although 
not an infallible sign of a cavity, the evidence is very nearly conclu- 
sive if it be confined within a circumscribed space, at the summit of 
the chest. Piorry calls it a " water-sound," under the supposition 
that air and liquid contained in a cavity are necessary for its pro- 
duction. This opinion, according to Skoda, is disproved by experi- 
ments. 

The cracked-metal sound, as the title implies, resembles that pro- 
duced by striking a cracked metallic vessel. It may be imitated by 
folding the palms of the hands loosely and striking the dorsal surface 
on the knee, in the manner frequently done to amuse children, pro- 
ducing a sound as if pieces of money were placed between the palms. 
This, like the ordinary amphoric resonance, usually denotes a cavity, 
but not invariably. Several observers have noticed it in children at 
the summit of the chest in thoracic afi*ections without excavation, 
and even when no pulmonary disease existed. Two striking instances 
have fallen under my own observation. In one, a child five years of 
age the sign was marked in the left infra-clavicular region, and after 
death there was found an abundance of tuberculous deposit without 
excavations, but lying directly beneath the left bronchus, was a mass 
of tuberculous matter, the largest collection found anywhere being 
about the size of an English walnut. In the other case alluded 
to, the child was reduced to extreme emaciation, but without cough or 
other symptoms of pulmonary disease. The sign in the latter case 
was so well marked that the patient was several times presented to a 
medical class to illustrate the peculiar character of the cracked-metal 
resonance. The production of this sound is now generally attributed 
to the air being suddenly and forcibly expelled from a cavity commu- 
nicating with the bronchige by several free openings, precisely as the 
blow on the knee expels the air between the palms in the experiment 
mentioned by which the sound may be imitated. To elicit the sound 
a forcible percussion is necessary, and a single blow is better than 
several strokes repeated in quick succession. The patient's mouth 
should be open. If the mouth and nostrils are completely closed the 
sign is not heard. This fact appears to demonstrate the production 



PERCUSSION IN DISEASE. 121 

of the sound in the manner just stated. When it occurs in children 
without the existence of a cavity, it is due to the air being expelled 
from the larger bronchial tubes as it is from an excavation. Percus- 
sion at the summit of the chest in children may be brought to 
bear on the bronchial tubes with greater effect than in adults, 
owing to the greater elasticity of the costal cartilages in early life. 
The sign, however, has been observed in adults in cases in which 
consolidation of the lung existed. Occurring at the summit of the 
chest in a circumscribed space, especially if not near the sternal 
extremity of the infra-clavicular region, and if associated with 
symptoms denoting advanced tuberculous disease, the cracked-metal 
resonance is almost conclusive evidence of the existence of a cavity, 
but the evidence may frequently be rendered complete by its associa- 
tion with other signs. 

It would be an error to suppose that either of the preceding 
varieties of tympanitic resonance is found, save in a very small 
proportion of the cases in which excavations in the lungs have taken 
place. For the peculiar sounds to be produced, the cavity must be 
of considerable size ; the walls must be sufficiently rigid, not to 
collapse, when free of liquid contents ; it must be situated near the 
superficies of the lung, or the pulmonary substance between the cavity 
and the walls of the chest must be solidified ; and other conditions may 
be essential, the importance of which is not so appreciable. Cavities 
resulting from circumscribed gangrene, or abscesses in connection with 
pneumonitis, do not embrace the necessary physical conditions, and 
the signs are therefore chiefly significant of tuberculous excavations. 
They may occur in connection with pouch-like enlargement of the 
bronchise. 

It would also be an error to infer that whenever a cavity gives rise 
to well-marked tympanitic resonance on percussion, the sound is 
necessarily either amphoric or of the cracked-metal character ; a 
tympanitic, i. e. a non-vesicular resonance, may be elicited over a 
cavity without any special modification of the quality of the sound. 
Under these circumstances, how is a cavernous resonance to be dis- 
tinguished from the resonance which in some cases of tuberculous 
disease is found at the summit of the chest prior to softening and 
excavation ? Guided by the evidence which percussion alone affords, it 
would certainly be difficult, if not impossible, to make the discrimi- 
nation. If a distinct tympanitic resonance, with no peculiarity of 
character, be found over a circumscribed space, at the summit of the 



122 PHYSICAL EXPLORATION OF THE CHEST. 

chest on one side, the sound elicited around the border of this space 
being dull, the evidence thus derived solely by percussion of the exis- 
tence and situation of a cavity, is very strong ; and the evidence 
becomes quite conclusive if, the disease having been of considerable 
duration, and attended by pretty copious expectoration, it should be 
found by percussing at different periods of the day, that the tympa- 
nitic resonance is sometimes present, and at other times absent ; b 
the former being observed to occur after free expectoration, and the ; 
latter Tvhen there is reason to suppose that the cavity is filled with \ 
the morbid products which are expectorated. Occasionally a tympa- 
nitic resonance at the summit of the chest, on one side, is found to 
be suddenly developed in a circumscribed space, in which previous 
dulness had been ascertained to exist, and this occurs after a more 
or less copious emission of puruloid matter by expectoration. Under 
these circumstances the evidence of a cavity is quite conclusive. 

The physical diagnosis of excavations, however, does not rest ex- 
clusively on the evidence afforded by percussion. Important signs 
are obtained by other methods of exploration, especially auscultation. 
So far as percussion is concerned, indeed, the results of percussion 
are much oftener negative than otherwise, owing to the cavities being 
more or less filled with liquid, or other cii'cumstances not being 
favorable for the production even of simple tympanitic resonance. 



Summary. 

The abnormal sounds developed by percussion are distinguished 
from each other, and from the normal thoracic resonance, by varia^ 
tions in timbre, or quality, in intensity, in pitch, and in duration. 
Por practical purposes it suffices to arrange them into divisions based 
on differences in intensity and in quality ; variations in pitch and 
duration furnishing incidental characters. Thus arranged, the several 
classes of abnormal sounds are as follows: 1, exaggerated vesicular 
resonance ; 2, diminished resonance : 3, absence of resonance ; 4, 
tympanitic resonance. 

1. Exaggerated vesicular resonance is characteristic of vesicular 
emphysema. It is highly distinctive of that affection, unless the 
distension of the cells and expansion of the thoracic walls be very 
great, when the sonorousness may be diminished. Exaggerated re- 
sonance from emphysema retains the vesicular quality distinctive of 



SUMMARY. 123 

normal resonance, but this quality may be diminisbed more or less, 
and the sound approximate in timbre to the tympanitic. In propor- 
tion as the latter alteration takes place, the pitch is raised. 

2. Diminished resonance, or dulness, occurs, as a general rule, 
when a thin stratum of liquid removes the lung a short distance from 
the chest ; when the pulmonary substance is condensed by pressure 
of liquid effusion within the pleural sac, or, more rarely, by fluids in 
the bronchial tubes, by serous effusion within the cells or areolar 
tissue, and by vascular engorgement ; by tumors encroaching on the 
thoracic space, and by deposit of solid products within the lungs, viz., 
coagulable lymph, tubercle, carcinomatous matter, and a bloody clot ; 
cceteris paribus, the degree of dulness is in proportion to the extent to 
which the air-cells are compromised, and the relative quantity of air 
to the solid parts reduced. Important exceptions to this rule are 
observed. In a large proportion of cases of pleural effusion, the per- 
cussion-sound above the level of the liquid, for a variable period 
during the progress of the disease, is exaggerated, and in its charac- 
ter tympanitic. The same is true of the percussion-sound over the 
healthy lobe on the side in which the lower lobe is solidified in pneu- 
monitis. A tympanitic resonance is propagated from the stomach 
and intestines in cases of solidification of the lower lobes, more espe- 
cially the left lobe. It accompanies also, sometimes, partial solidifi- 
cation from tubercle, or other deposits at the summit of the chest. 
Whenever the sound becomes dull, the pitch is raised, and the dura- 
tion shortened. The pitch is also higher when it becomes tympanitic. 
The diseases in which diminished resonance occurs, with the excep- 
tions just stated, are pleurisy and hydrothorax, above the level of the 
liquid ; pneumonitis ; oedema of the lungs ; great congestion ; pulmo- 
nary apoplexy ; carcinoma, and tuberculosis. 

3. Absence of resonance, or flatness, is occasioned by an accumu- 
lation of liquid in the pleural sac, and exists below the level of the 
liquid ; sometimes by complete solidification in pneumonitis, and by 
tumors, or morbid growths. An increased sense of resistance, under 
these circumstances, is marked. 

4. Tympanitic resonance embraces all abnormal sounds (exclusive, 
of course, of flatness, which is, strictly speaking, absence of sound), 
which are non-vesicular. It exists in the most marked degree in 
cases of pneumo-hydrothorax. But in this affection, if the walls of 
the chest are distended so as to be made quite tense, the sound may 
become dull, although in character still tympanitic. The sound 



124 PHYSICAL EXPLORATION OF THE CHEST. 

transmitted from the stomach or intestines, when percussion is made 
over solidified lung, is purely tympanitic. The sonorousness some- 
times existing over condensed lung, or lung solidified by morbid 
deposits, at the summit of the chest, is also more or less tympanitic. 
A tympanitic resonance may also be developed by percussion over 
tuberculous excavations. In the latter case it is circumscribed in 
extent. Tympanitic resonance, under these circumstances, occasion- 
ally presents a ringing metallic intonation, and it is then called 
am^horio resonance. This modification is sometimes observed when 
sonorousness exists over solidified lung. Another modification is a 
cracked-metal soimd [bruit de pot fele), sometimes produced by per- 
cussing over a cavity of considerable size, superficially situated, 
having rigid walls, and communicating freely by several orifices with 
the bronchial tubes. The same peculiar sound, however, has been 
repeatedly observed in children at the summit of the chest, being 
caused by the forcible expulsion of the air from the bronchial tubes. 



History. 

Percussion was first proposed as a means of determining the nature 
and seat of diseases by Leopold Auenbrugger, born in Grraetz, in 
Styria, in 1722. Auenbrugger was the author of two works on mad- 
ness, of a di'ama, and wrote on dysentery. His work on percussion 
was thus entitled : Inventum novum ex percussione thoracis Humani 
ut signo alstrusos interni pectoris morhos detergendi^ The author 
died in 1809. The subject attracted scarcely any attention, and had 
fallen into oblivion, when, thirty years afterward, the method was 
applied to the diagnosis of afi'ections of the heart, by the distinguished 
French physician Corvisart, who translated Auenbrugger's treatise 
into the French language in 1808. The latter was translated into 
English by Dr. Forbes in 1824. 

The value of percussion was immeasurably enhanced by the dis- 
covery of auscultation. Of those who have cultivated the art of per- 
cussion, since the time of Corvisart, M. Piorry, of Paris, is by far the 

' One cannot avoid an emotion of sorrow at the thought that Auenbrugger, who de- 
voted seven years to researches, as he says iyiter tedia et labores, could not have enjoyed 
during his Ufetime the satisfaction of seeing the importance of percussion in some 
measure appreciated. In this respect the discoverer of auscultation was far more 
favored. 



HISTORY. 125 

most prominent. Mediate percussion was introduced by him. He is 
the author of several works on the subject.* In practice, however, 
he places too exclusive reliance on this method, rejecting auscultation ; 
and he professes to achieve results with the pleximeter, to which 
others with equal ability, and not less conscientiousness, have failed 
to attain. 

The idea of combining auscultation with percussion may be said to 
have originated with Laennec. He resorted to it, however, to a 
very limited extent. The plan of practising the two methods simul- 
taneously, with a view especially of determining accurately the situa- 
tion and dimensions of the solid viscera encroaching on the thoracic 
space, which, although it has not come into general use, and perhaps 
never will, in consequence of the ordinary simpler modes being ade- 
quate to most of the objects to be attained by percussion, originated 
with Drs. Cammann and Clark, of New York. 

^ Trait^ de la Percussion mediate, Paris, 1828. and Du Precede op^ratif de la Per- 
cussion, Paris, 1831. The views of M. Piorry are also embodied in a more recent 
j work, by one of his pupils, M. Maillot, Traitd de la Percussion mediate, etc. The latter 
I has been translated into English, but not republished in this country. 



CHAPTER III. 
AUSCULTATION. 

The term auscultation is applied to the act of listening to the j 
sounds produced within the chest, in connection with respiration, 
speaking, and coughing. The use of the term in this restricted sense 
is conventional. Properly speaking, the phenomena developed by 
percussion, involving, as they do, in their application equally an act j 
of listening, should come witliin the domain of auscultation. There 
is, however, this distinction, viz., in percussion the sounds are pro- 
duced by the manipulations of the listener, while in auscultation they 
result from the actions, either instinctive or voluntary, of the patient. 
The explorer, in the one case, is an active agent in originating the j 
impressions received through the sense of hearing ; in the other case j 
he is little more than a passive recipient. Another point of dif- 
ference is. that percussion may be practised on the dead as well as 
on the living body, while auscultation is available only so long as life 
continues. 

The act of listening to sounds emanating from the thorax, may be 
performed in two ways, viz., with the ear applied directly to the 
chest, or by means of a conducting medium. These two modes are 
distinguished by the same terms employed for an analogous purpose 
in percussion, viz., 7nediate and immediate.^ In immediate ausculta- fc 
tion, the sounds are received by the ear placed in immediate contact li 
with the chest. Mediate auscultation requires an instrument, which i 
is interposed between the chest and the ear of the listener, through ^ 
which the sounds are transmitted. This instrument is called the 
stetJiosc'oj^e, a term signifying chest-explorer. 

The question at once arises, of the two modes of practising aus- 
cultation, which is to be preferred ? Each mode has its peculiar ad- 
vantages, and neither should be adopted to the exclusion of the other. 
Immediate auscultation is the simpler mode ; it is in most cases prac- 

^ These terms were first employed by Laermec. and subsequently borrowed and applied 
to percussion by Piorry, 






AUSCULTATION. 127 

tised more readily, and the exploration of tlie wliole chest is more 
expeditiously made. In a large majority of cases, to one practically 
familiar with auscultatory phenomena, it suffices for all that is desired 
with respect to the diagnosis. With children, who are apt to be 
frightened at the appearance of an instrument, this mode is often 
alone available. But in certain parts of the thoracic surface the ear 
cannot be applied, for instance, the axilla and the post-clavicular 
region. If the patient be so feeble as not to be able to be raised 
from the recumbent posture, and the bed be low, the position, on the 
part of the explorer, necessary to practise immediate auscultation, 
renders it inconvenient and difficult. The uncleanly condition of 
patients is often not a trifling objection ; and with females, delicacy, 
or, at all events, fastidiousness, may oppose a resort to this mode over 
the anterior surface of the chest. 

Mediate auscultation becomes almost necessary in some instances, 
in which it is important to isolate the phenomena produced at a par- 
ticular point from those of the surrounding parts. When the head 
is placed in apposition to the thoracic walls, sounds emanating from 
a considerable distance are brought within the focus of hearing, being 
conducted by the parts surrounding the ear which is in contact 
with the chest. With the stethoscope, the area whence the sounds 
are transmitted is more circumscribed, and this is an important advan- 
tage under some circumstances, as in seeking for the auscultatory 
signs of an excavation, or of tuberculous consolidation contained within 
narrow limits. In some cases in which the surface of the chest has 
been rendered very irregular by injuries, or deformities, auscultation 
is available only by means of the stethoscope. Neither mediate nor 
immediate auscultation, then, is to be cultivated or practised to the 
entire neglect or exclusion of the other, but each is to be resorted to 
as it may be specially indicated, and frequently both employed in the 
same examination. 

The part performed by the stethoscope in auscultation was much 
exaggerated by the illustrious discoverer of this method of explora- 
tion, and is still misunderstood by many. Laennec appears to have 
regarded it in the light of an ear trumpet rendering sounds more 
audible than they appear to the unassisted ear. It is simply a 
conducting medium. It does not augment sonorous vibrations. 
And the glory which will ever attach to the name of Laennec, as 
has been justly remarked, is in no measure derived from the in- 
vention of the stethoscope, but solely from the discovery of auscul- 



128 PHYSICAL EXPLOKATION OF THE CHEST. 

tation. A great variety of stethoscopes are in use. Almost every 
one who has bestowed special attention on this branch of practical 
medicine, seems to have felt it incumbent to originate an instru- 
ment possessing some one or more peculiarities which frequently 
are of no practical importance. The material of which it is made, its 
size, length, form, etc., offer wide scope for diversity of construction. 
But the truth is, that if the sounds are conducted to the ear, the 
construction of the instrument is in a great measure a matter of 
taste or convenience. The conducting power, indeed, is of less con- 
sequence than might be at first imagined, provided the sounds are 
fairly transmitted ; for intensity, as a general remark, is of less value 
than other features by which auscultatory signs are recognized and 
discriminated, and often it is of very little account whether the phe- 
nomena due to respiration are strongly or feebly conveyed to the ear, 
if they are distinctly appreciable. The first stethoscope constructed 
by Laennec was composed of three quires of writing paper rolled 
compactly in the form of a cylinder and secured by paste. After- 
ward a cylinder of wood was substituted, and of this material the 
instruments emploj^d since the time of Laennec have generally 
been made. Wood is not the best medium for the transmission of 
sound, but owing to its lightness, and some other recommendations, 
it is to be preferred to metal or glass, which are better conductors. 
Instruments have lately been constructed of gutta percha ; with these 
I have had no practical acquaintance. They are recommended as 
fulfilling all the conditions of a convenient stethoscope by competent 
authority.^ It would be quite unnecessary, to say the least, to enter 
into a discussion of the numerous details pertaining to the length, size, 
form, etc., of the cylinder. It will suffice to notice, briefly, the gene- 
ral principles to be observed in its construction. Some (Hughes, Wat- 
son, and Blakiston) prefer solid wooden cylinders. Most of the in- 
struments, however, in common use are perforated through the centre, 
and the general impression is, that the sound is conveyed partly along 
the woody fibres, and in part by the column of air enclosed within the 
canal passing through the cylinder. Of the different kinds of wood, 
either cedar or ebony is usually selected from their lightness and 
straightness of fibre. The instrument should be of sufficient length 
for the head to be removed to a comfortable distance from the body of 
the patient ; but if it be too long, there will be difficulty in keeping it 

* Dr. J. Hughes Bennett. 



AUSCULTATION. 129 

accurately adjusted to the chest. Six to ten inches are the limits 
of a convenient length. The end applied to the ear (the aural 
extremity), should be broad and moderately concave, so as to receive 
the external ear, and admit of pressure upon the whole surface, with 
the head, without closure of the meatus. Many stethoscopes are 
faulty in these points ; the aural extremity is too small, and the con- 
cavity either too great or insufficient. But the same instrument will 
not equally fit the ears of all persons, and, as Dr. Walshe remarks, 
''it is as necessary to try on a new stethoscope as a new hat." It is 
better that the ear piece be of the same material as the body of the 
instrument. It is frequently made of ivory, which may be more 
pleasing to the eye, but diminishes somewhat the conducting power. 
The end applied to the chest (pectoral extremity), should be trumpet 
or funnel-shaped, and not too large. A diameter of an inch, or an 
inch and a half, is sufficient. The edges should be rounded so that the 
requisite amount of pressure shall not hurt the skin. For the sake 
of lightness, the body or stem of the instrument may be reduced in 
size to a cylinder of the diameter of half an inch, if the material 
be ebony, or an inch or so, if it be cedar. The exterior and the bore 
of the instrument, should be smooth and polished. "With these few 
data the student or practitioner might cause one to be constructed, or, 
imitating the example of Laennec, construct one with his own hands 
without any model. Stethoscopes, however, are so common, that it is 
only necessary to select from a variety of specimens the one which 
appears best to combine the conditions just stated. Habit will be 
found to have much to do with the ease and facility with which a 
particular instrument is employed ; and it is undoubtedly true that a 
stethoscope defective in certain points of construction will be pre- 
ferred by one accustomed to its use, over another which is in reality 
superior, but to Avhicli he is not habituated. 

Flexible stethoscopes are used to some extent, and by some pre- 
ferred to the wooden cylinder. Their introduction in this country is 
due to Dr. Pennock, of Philadelphia. A flexible instrument several 
years ago was devised by Dr. Pennock, constructed of coiled me- 
tallic wire, covered with a silk or worsted web ; the pectoral 
extremity consists of a metallic cone, and to the aui-al extremity a 
tube is attached, also of metal, which is introduced within the exter- 
nal ear. The chief recommendation of a flexible stethoscope is that 
it admits of application to difi'erent parts of the chest, without the 
necessity of much change of position on the part either of the patient 

9 



130 PHYSICAL EXPLORATION OF THE CHEST. 

or operator. In some instances this is an important desideratum. 
The instrument is a sufficiently good conductor of the thoracic sounds. 
A disadvantage of it is, that the pectoral extremity requires to he held 
in apposition to the chest with one hand, and the aural extremity 
kept within the ear by the other hand. Sounds produced by the con- 
traction of the muscles of the hands, and by friction on the instru- 
ment, are apt to be commingled with those received from the chest. A 
little practice, however, enables the listener to disconnect the latter 
and observe them separately. In this variety of stethoscope, if not 
indeed, in the ordinary wooden cylinder, the column of air appears 
to be the important conducting medium ; and, in fact, a common 
ear-trumpet, with a caoutchouc tube, answers the purposes of a 
stethoscope. M. Landouzy, of Paris, has suggested a stethoscope 
with a number of gum-elastic tubes, by means of which several 
persons may auscultate simultaneously. Dr. Marsh, of Cincinnati, 
has invented and patented an instrument with two tubes. A peculiar 
feature of the latter is a gum-elastic membrane stretched across the 
pectoral extremity. I cannot speak of this instrument from any 
practical knowledge of it. 

Quite recently a flexible stethoscope on a novel plan has been in- 
vented by Dr. Cammann, of New York. It consists of a bell-shaped 
pectoral extremity, made of ebony, and about two inches in diameter, 
to which are attached two tubes of metallic wire covered with gum- 
elastic, and with the latter are connected two tubes of German silver, 
gently curved, and ending in ivory knobs, which are intended to be 
introduced within, and to fill accurately, the external ear on each side 
at the same time. The sounds are thus received through both organs 
of hearing, and other sounds than those transmitted by the instrument 
are excluded. 

In the construction of this instrument the agency of the column of 
air in conducting the thoracic sounds is supposed to be established 
experimentally ; for it is stated that the solid media were changed 
many times without the conducted sound losing its intensity, and the 
sound was lost by making the pectoral extremity solid. Thoracic 
sounds are heard by means of this instrument with great intensity ; 
and are rendered distinct when scarcely appreciable by the naked ear, 
or with the ordinary cylinder. In the latter respect it serves virtually to 
enlarge the application of auscultation by developing positive results in 
cases in which, by former modes of examination, the signs are negative. 
It also renders auscultation available to those whose sense of hearing 



ATJgCULTATIOy. 1^ 

is impairecL CoiiduciDg. however, in a striking degree to the inten- 
sity of sound, the quality and pitch are altered, as indeed, is stated 
by the inventor. In making trial of the instroment, I have foxmd it 
more difficnlt to institute comparisons as regards quality and pitch of 
sound than with the ear alone, or the ordinary stethoscope ; but witli 
reference to differences of intensity, and in rhythm, it adndls of a 
wider application than the common modes. It renders distinctly 
audible, also, morbid sounds in some instances in which tJiey are too 
obscure to be studied satisfactorily withont its ^d- For eompanson 
of the two sides of the chest as respects the resonanee prodaced by 
the act of speaking, it is exceedingly well adapted. 

With these advantages the invention is entitled to be eoogadesred a 
valuable contribution to the means of physical exploration. In nang 
the instrument it is to be borne in mind that it condnets sounds ]VO- 
duced exterior to the chest in no less a degree than those aaanatiiig 
from within the thorax. The slightest friction of any sabstanee upon 
it gives rise to a loud soimd. The pectoral extremity most be xpp^ed 
to the naked skin to avoid this source of extrinsie sounds. It is 
intended to be a self-adjusting stethoscope, but in order to keep it 
firmly and equally applied, I have found it neeessaiy to hold the 
pectoral extremity between the fingers ; this is a source of extrane- 
ous sounds which by practice are to be guarded against as much as 
possible, and recognized when they are produced.* 

With the aid of an assistant, or of the patient himself, in keeping 
the pectoral extremity of this stethoscope to the chest, it most be admi- 
rably suited for auscultatory percussion, as proposed by its inventor 
in connection with Prof. Gark. 

In the performance of auscultation certain rules are to be observed, 
the more important of which may be here stated. Whenever practi- 
cable, the person to be exaniined should be seated in a chair with a 
high back, famishing a firm support for the shoulders, which are to 
be thrown moderately backward when the chest is explored in front. 
In examining the back a stool is preferable, or, if the padent be of 
the male sex, his position may be reversed, the face tamed to the 
back of the chair ; the body should be inclined forward, the arms 
folded as in practising percussion on the posterior smface of the 
chest. In exploring the lateral surfaces the hands shoold be clasped 
upon the head, as when percussion is made in this situation. If the 



' Bf. Caznmann's stethoscopes are man i ifirture d and sold hf MeasarsL Genge Tk 
k Co^ No. 63 CbBtfaam Sl, New York. 



132 PHYSICAL EXPLORATION OF THE CHEST. 

I 
patient be confined to the bed, the chest in front may be examined 't 

in the recumbent posture, and afterward, if the disease be not accom- 
panied by extreme debility, he may be raised, and supported in a 
sitting position while the examination is made behind and laterally. 
It is sometimes the case that patients are too feeble to endure a ver- 
tical position of the body even for a short time. Inclining the body 
first on one side and then on the other, a partial exploration may 
be made under these circumstances, by means of the flexible stetho- 
scope. It rarely occurs, however, that when a careful examination 
of the back is desirable, a favorable position is impracticable. It is 
more satisfactory to divest the chest of all clothing, in order to judge 
better of corresponding points on the two sides to be explored in alter- 
nation. So far, however, as concerns the transmission of sounds, 
this is not necessary. A single thin covering of cotton or linen 
offers little or no obstruction, nor is it a serious hindrance to deter- 
mining often with sufficient accuracy the particular parts of the chest 
to be examined in succession. Several thicknesses, or a thick woollen 
article of dress, interferes with the appreciation of auscultatory pheno- 
mena. If a covering remain, it should be soft and flexible, so as not 
to occasion a rustling noise from the movements of the chest, or by 
friction against the ear or stethoscope. In immediate auscultation a 
soft napkin, or handkerchief, may be interposed between the skin and 
the ear, in order to obviate the disagreeable circumstances often atten- 
dant on applying the head to the naked surface. A regard for delicacy 
prevents complete exposure of the chest of the female. The portions, 
however, most important in cases in which a minute and visual 
examination is most likely to be required, viz., the summit in front 
and behind, may, without impropriety, be divested of the dress. The 
temperature of the room should be properly regulated, especially if 
the chest be exposed. This is important not only to obviate the 
liability of the patient suffering injury from the impression of cold 
on the surface, but to prevent a difficulty which may interfere with 
the examination. The action of cold on the muscles of the chest 
sometimes occasions trembling movements accompanied by a rumbling 
noise which obscures the intra-thoracic sounds, and without knowledge 
of this source of an exterior murmur, it might be supposed to ema- 
nate from within the chest. The position of the explorer should be 
one favorable for listening with attention, and which may be main- 
tained for some time without fatigue or discomfort. If he assume a 
-constrained posture his mind will be diverted from the object of ti 



AUSCULTATION. 133 

the examination to his own sensations, and he will be unable to re- 
serve his perceptions exclusively for the thoracic sounds. A stooping 
posture is, as much as possible, to be avoided, not only for the reason 
just mentioned, but because the gravitation of blood to the head in- 
duces a temporary congestion, which dulls the sense of hearing. It 
is not uncommon to see practitioners inclining their heads so low in 
performing auscultation that the face becomes deeply injected, and 
the veins largely dilated. I find it most convenient and comfortable 
to rest upon one knee. In this position the head may be placed in 
contact with the chest, and kept upright, or nearly so. Of course 
these precautions have reference to the practice, either of imme- 
diate auscultation, or the use of the wooden cylinder. With a flexible 
stethoscope from one to two feet in length, the explorer may remain 
sitting by the side of the patient, the latter lying, or seated, as the 
case may be. This is one of the recommendations of this instrument 
to be placed against its disadvantages. 

The ear is to be pressed against the chest, or on the cylinder, with 
a certain amount of force. If the pressure be made too lightly the 
sounds are not transmitted, or an unnatural character may be com- 
municated to them which may be mistaken for morbid phenomena. 
Thus the resonance of the voice by the non-observance of this rule, 
sometimes assumes a modification analogous to that incident to cer- 
tain morbid conditions, constituting the physical sign called gegophony. 
On the other hand, if too great force be applied, pain may be occa- 
sioned sufficient to disturb the respiratory movements, or the expan- 
sion of the chest may even be mechanically impeded. Attention to 
this point, with practice, will enable the auscultator to hit the medium 
between the two extremes. If the cylinder be employed, the pec- 
toral end should be evenly applied on the chest, and held in place 
with the fingers of the right hand until the ear is nicely adjusted to 
the aural extremity. The hand is then to be removed from the in- 
strument, which is to be kept in place by means of pressure with the 
ear alone. Non-observance of this rule is one of the circumstances 
by which a mere formalist in the practice of auscultation may be 
detected. 

In practising auscultation it is well to accustom oneself to the use 
of either ear indiff*erently, if the sense of hearing be equally acute 
in both. An exploration of both surfaces of the chest can then be 
made without the necessity for change of position on the part of the 
explorer. Perfect silence in the apartment is at first necessary. The 



134 PHYSICAL EXPLORATION OF THE CHEST. 

habit of mental abstraction, and the power to concentrate the attention 
exclusively on the thoracic sounds, are not generally acquired with- 
out more or less pains and perseverance. After a time, however, 
extrinsic noises are less troublesome, and an exploration may be made 
under unfavorable circumstances. The ability of acquiring the power 
to withdraw the senses and thoughts from surrounding objects is not 
equally possessed by all individuals, and it is owing in part to dif- 
ferences in this respect that some persons become much better 
auscultators than others. Every one accustomed to physical explo- 
ration must have observed that the facility and satisfaction with 
which examinations are made, differ considerably at different times, 
owing to differences in the state of mental activity, preoccupation, 
etc. After auscultating for a time, the quickness and correctness 
with which thoracic sounds are perceived are liable to be impaired 
by fatigue. It is a useful caution, therefore, not to continue this 
kind of investigation too long. From one to two hours of continuous 
exploration is sufficiently long without an interval of rest. 

The acoustic phenomena revealed by auscultation relate to the 
respiration, the voice, and the act of coughing, the latter being 
comparatively of little consequence. In listening to^ the respiratory 
sounds, the manner in which the patient breathes is a matter of im- 
portance. Mental excitement or apprehension often gives rise to 
more or less disturbance of the respiration. The breathing becomes 
hurried and irregular, and, on this account, the examination may be 
unsatisfatory, or even prove abortive. In persons of great nervotis 
impressibility it is frequently necessary to wait until calmness is 
restored before proceeding with, or completing an exploration. As 
justly remarked by Fournet, the manner and bearing of the physician 
have much to do with this point. If he wear a solemn mien, and 
favor by his looks or actions the idea that the operation is one of 
formidable import, he will be less successful than if he manages to 
divest it of repulsive features. With reference to this end immediate 
auscultation, in which no instruments are exhibited, is to be preferred, 
whenever the object can be equally well attained by that mode. It 
is generally desirable to cause the patient to breathe with more than 
ordinary force in the progress of the examination, and it is sometimes 
extremely difficult to effect this object satisfactorily. He accelerates 
the respu'ation, or takes a deep inspiration and holds his breath, or in 
different ways alters the rhythm of the respiratory acts. The end de- 
sired is simply to render the breathing somewhat more intense without 



'AUSCULTATION. 135 

change in other respects ; and the best mode of securing the end is 
to breathe ourselves just as we wish the patient to do, requesting him 
to observe and imitate us as closely as possible. Another method is 
to request the patient to cough while the ear is applied to the chest, the 
respiration succeeding an act of coughing being deeper or fuller than 
ordinary. In some instances the respiratory phenomena are not ap- 
preciable except the force of the breathing be voluntarily or involunta- 
rily increased. It is necessary to caution the unpractised auscultator 
to avoid mistaking the noise frequently produced by the current of 
air at the mouth of the person examined, for sounds emanating 
from the thorax. The patient should be instructed to avoid making 
labial sounds, which by entering the ear not applied to the chest, 
tend to distract the attention, if they do not lead to the error 
just mentioned. In auscultating the voice, the plan usually adopted 
is to cause the patient to count from one to five, repeating these 
numbers as often as may be requisite, being careful to utter each 
numeral with the same tone and strength. 

In auscultation, as in percussion, the phenomena of disease are not, 
as a general remark, determined by reference to any fixed standard 
of health applicable alike to all individuals. It will be seen presently 
that auscultatory, not less than percussion-sounds, differ widely 
within healthy limits. Hence here, as in the practice of percussion, 
a comparison is instituted between the two sides of the chest. The 
laws of disease, in a large proportion of cases, permitting one side 
of the chest to retain the phenomena of health, enable us to judge 
of morbid phenomena by means of a want of correspondence be- 
tween the two sides. This remark does not apply to auscultation 
to the same extent as to percussion, for several of the phenomena 
revealed by the former are in themselves, irrespective of such a com- 
parison, well-marked physical signs of disease. But in certain in- 
stances, as will be seen hereafter, a close comparison of corresponding 
points of the two sides is very necessary in determining the exis- 
tence of morbid phenomena. When this is the case, observance of 
uniformity in every particular in auscultating each side in succession 
is not less necessary than in practising percussion. The enuncia- 
tion of this general rule will suffice, without stopping to dwell upon 
details. Comparison of points in exact correspondence, taking 
care to make an equal amount of pressure with the ear, causing the 
respiratory movements or the voice to be as nearly identical as possi- 
ble, etc., are points not to be overlooked when nicety of discrimination 
is involved in the diagnosis. 



136 PHYSICAL EXPLORATION OP THE CHEST. 

Finally, to employ auscultation successfully, the explorer must be 
qualified by knowledge and practice to appreciate the sounds incident 
to respiration and the voice, in the different aspects in which morbid 
deviations from health are liable to be presented ; he must be pre- 
pared, in other words, to recognize the morbid phenomena which may 
exist, and to do this he must make himself conversant theoretically, 
and as far as opportunities are offered practically, with the facts and 
principles which have been established by the labors of those who 
have devoted attention to the subject. Otherwise he is met by all 
the difficulties which the pioneers in the cultivation of this field of 
research were obliged to encounter ; difficulties, thanks to the genius of 
the illustrious founder of auscultation, and the labors of his successors, 
no longer existing to retard and limit the progress of one who at this 
day aims to become a proficient in physical exploration. 

In the study of auscultation, as of percussion, the point of departure 
for investigating the signs of disease is an acquaintance with the phe- 
nomena pertaining to the healthy chest. The remainder of this 
chapter, therefore, will be divided into, 1. Auscultation in Health, 
and, 2. Auscultation in Disease. 



I. Auscultation in Health. 

It is essential to the application of auscultation to the diagnosis of 
disease to become practically familiar with the sounds produced by 
respiration and the voice in health, for without this knowledge it 
would be impossible to determine whether sounds heard in cases of 
suspected disease are natural or morbid. But there is an additional 
reason why the study of the auscultatory phenomena pertaining to 
the respiratory system in health is to be commended to the student's 
careful attention before he enters on the subject of the signs of disease, 
viz. : by means of this preparatory knowledge he is at once qualified 
to appreciate some of the more important of the morbid sounds. 
Incongruous as it may at first appear, it will be found to be true, that 
certain of the most valuable of the physical signs involved in diagnosis, 
may be studied in persons entirely free from disease. This fact will 
appear in the sequel. In treating of Auscultation in Health we are 
to consider the phenomena incident to respiration, to the voice, 
and to the act of coughing. We will consider these phenomena under 
separate heads. 



AUSCULTATION IN HEALTH. 137 



PHENOMENA INCIDENT TO RESPIRATION. 

These phenomena are by no means the same in all parts of the 
respiratory apparatus, and it is highly important to study them in 
different portions of this apparatus separately. The respiratory 
sounds are widely different, according to the sources whence they are 
supposed to emanate. As distinguished by their origin, either in the 
air-vesicles, or different parts of the air-tubes, they may be arranged 
into three classes, viz. : 1. Those situated in the trachea, and in this 
class may be included laryngeal sounds ; 2. Those produced within 
the larger bronchi; 3. Those originating in the smaller tubes and 
vesicles. The phenomena thus in,cident to tracheal, bronchial, and 
vesicular respiration are to be investigated separately, and contrasted 
with each other. 

1. Tracheal Respiration. — To auscultate the trachea the ste- 
thoscope is necessary, which is to be placed in front just above the 
sternal notch. Applied in this situation a sound is almost invariably 
found to accompany each respiratory act. The sound with both inspi- 
ration and expiration has a certain timbre or quality, conveying to 
the mind the idea of a current of air forcibly impelled through a tube 
of considerable size ; hence it may be distinguished as a tuhidar sound. 
This term tubular it is convenient to use by way of distinction. Occa- 
sionally the sound has a ringing, metallic quality. The respiratory and 
the expiratory tracheal sound present some differences, and merit sepa- 
rate notice. The sound with inspiration, if observed for some time, will 
be found to vary considerably with different respirations as regards 
intensity. Generally, it is quite intense with ordinary breathing, 
but it always becomes much more so when the force of the breath- 
ing is voluntarily increased. The intensity with forced, but still 
more with ordinary breathing, differs considerably in different 
persons. Occasionally it is exceedingly feeble, almost inaudible, 
except when the force of the breathing is increased. Compared 
with the expiratory sound as regards intensity, it is frequently, but 
not generally, more intense in ordinary respiration, but almost in- 
variably in these cases becomes less intense than the expiratory sound 
in forced breathing. In duration the inspiratory sound falls a little 
short of the period occupied by the inspiratory act. It attains its 
maximum of intensity quickly after the first development of sound, 
and maintains the same intensity to the close of the act, when the 



138 PHYSICAL EXPLORATION OF THE CHEST. 

sound abruptly ends, as if suddenly cut off. As regards pitch, it may 
be remarked, that it is higher, ^. e. more acute, or sharper, than the 
sound emanating from the air-vesicles. 

The expiratory, like the inspiratory sound, varies in intensity con- 
siderably with different respirations, and is habitually feeble in some 
individuals, while it is strongly marked in others. This statement 
applies to ordinary respiration. When the respiration is forced, the 
sound almost invariably becomes intense. In tranquil breathing, its 
intensity is in some instances greater, and in some less, than that of 
the inspiratory sound ; but in forced breathing, it is almost invariably 
more intense. As regards pitch, it is, with a few exceptional or 
doubtful instances, more acute than the inspiratory sound with ordi- i 
nary respiration, and this is uniformly the case when the respiration i 
is forcibly increased. It presents oftener than the inspiration the 
quality called metallic. In duration, in the great proportion of in- 
stances, it is somewhat longer than the inspiratory sound ; and this is \ 
more marked in forced than in ordinary respiration. Occasionally 
the sounds with the two acts are about equal in length. The expira- 
tory, like the inspiratory sound, quickly attains its maximum of i 
intensity, but instead of preserving the same intensity, it gradually f 
becomes weaker, and ends, not abruptly, but is, as it were, lost imper- 
ceptibly. 

The inspiratory and expiratory sounds are not continuous, but 
separated by a brief interval. 

The foregoing description is based on observations in forty-four 
healthy persons, the facts being noted at the instant of observation 
and afterward analyzed. | 

The characters, then, distinctive of the tracheal respiration, taking, , 
as a type, a respiratory act somewhat more forcible than in ordinary 
breathing, are as follows : 

A sound of inspiration and of expiration ; both having a tubular 
quality ; both higher in pitch than the vesicular respiration ;^ a short 
interval separating the two sounds ; the expiratory sound more 
intense, longer, and higher in pitch, than the inspiratory. 

The student should practically verify these characters, and impress 
them on the memory. They will be seen hereafter to have an im- 
portant practical bearing on the study of disease. The tracheal 

' In order to appreciate this point of distinction in anticipation of the consideration of 
the vesicular respiration, the student may compare the two by listening to the respiration, 
with the ear applied to the chest after auscultating the trachea. .\ 



AUSCULTATION IN HEALTH. 139 

respiration, observed elsewhere tlian over the trachea, is a significant 
physical sign, of frequent occurrence. 

The laryngeal respiration is said by some writers on auscultation, 
to differ in a marked degree from the tracheal.' I have recorded com- 
parative observations made with care in eighteen persons, and in none 
of these instances were there any notable points of disparity save in 
intensity. Frequently the respiratory sounds heard by placing the 
stethoscope on the side of the larynx were less intense than over the 
trachea. In other characters they were essentially identical. 

It is foreign to my purpose to enter into much discussion concern- 
ing the laws of physics by which auscultatory phenomena are to be 
explained. It is easy to understand why a column of air moving to 
and fro, with considerable velocity and force, through the trachea, 
should give rise to a tubular sound. The sound may be imitated by 
blowing through a tube of uniform size, or through the larynx and 
trachea removed from the body. The different characters pertaining 
to the inspiratory and expiratory sounds, may probably be readily 
accounted for, by reference to the different circumstances belonging 
to the two acts respectively. The force of the inspiratory movement 
is sustained equally to its close ; hence the intensity of the inspiratory 
sound is maintained, and ends as abruptly as the act itself. On the 
other hand, the force of the expiratory movement is greatest at its 
beginning, and gradually diminishes ; hence, a corresponding diminu- 
tion in the intensity of the sound. The fact that the expiratory act 
involves more power, especially in forced breathing, explains the 
greater relative intensity of the expiratory sound ; and its greater 
length, the corresponding longer duration of the sound. The higher 
pitch of the expiratory sound is in part due to the greater force of 
this act ; but in part, probably, to the greater contraction of the 
glottis by the approximation of the vocal chords, which recent obser- 
vations have shown to take place with expiration, the space between 
the chords dilating regularly with inspiration. This approximation 
is greater in proportion as the respiration is forced, a fact which 
corresponds with the more marked elevation of pitch under these cir- 
cumstances. (Introduction, pages 33 and 53.) 

The tone and intensity of the tracheal respiration, may be readily 

' Ex. gr. Barth and Roger, " Sur le larynx meme le murmure varie encore ; il ressemble 
a I'esp^ce de souffle que determinerait I'entree de I'air dans nne cavit^ plus large; outre 
sa rudesse, il prend un caract^re caverneux beaucoup plus marqu6 et constitue le bruit 
respiratoire larynge." Op. cit. p. 36. 



140 



L ZXrLOSAnOS- OF IZ 



I 






^r-titli-soniids witK tlie moutli. Skoda has 
:'i 7 respiratory sounds peculiar to different 



present m tr^el&€al 

are ~li5: t. 7 _ 
■diis wa J n - 7 



iiispered letters. A similar mode of establisL.- 
: — : r:-r~"r?, lias been long since pnrsned by 

_.. "^ i_^ ,^i:oda, tlie letters ch, soft:, wiQ re- 

J„ 7 "litcli and " : : di7 55 may be yaried by 

1 ^-^ ;_ :^i7 lir is expelled wken these letters 

-1 _' : : _ 7 ~ L : the disposition of tKe lips. In 

:: ' -_7 : : 1' inspiration^ and tlie more 
7 T ._ \ 1 - _ . : 1 1 :^racterize the respiratory 



on maybe heard witli distinctness, and some- 
•:_-rnsity, wten tKe stettoseope is placed on 

.7 ;rrvTcaI vertebrse. 



2. BE,05"CHiAii KESPmAHOS". — Tik& normal broncMal respiration 

^2^ =:^-z. ' ^---'T-^d '.:• ':r ^T-T-'^^rr-ed within tKe broncKial tnbes on 



SUilL'. 



7 . 7 ^ 7,7 7 Inngs. TKe points wKere eitKer 

. nl, in order to obserre tKe pKe- 

. 7 - : :ie respiratory apparatus, are in 

~ ._ : _ 7 : ^ ^ „ ^ :ibs, close to tKe stemo-clavicnlar 
:_ " bekbid, in tKe interscapoLar space, on a line witK tKe 
.' ii- r- - , 7 - *i 7 - : - - ".: ^ A- - ' " : " - -er tKe upper part of tKe ster- 
infirr z - : d^ 7 : 7 . - : _ 7 _ 5, tKe somid must necessarily 
Hiaiiily from tKe tracKea. In fact, it is not probable tKat in tKe 
'~ aboTe tKe broncKi, tKe respiratory somids are 
purely te-: _- . ._ ^rir origin. TKe tracKeal respiration maybe 
lieord ^tsse m some, if not in a greater or less degree,^in most persons. 
GeB^Eallv. " -^ . r Tesicnlar respiration emanating from tKe air-cells, 
_ . 7 A :er or less degree, tKe eKaraeter of tKe sound. TKe 
feomeKial respiration is tKns, in reality, a mixed respiratory 
, acnd - 1 7 ' vfrrences wKicK are to be noled in di^rent individnals, 
aie to be en ,: ^ :. .1 7 ' ' - % great measure, Ky tlie e0«iBl)ination, in yarying 
propQiiisiLS, ;: ^ iree varieties, yiz., tracKeal, broncKial, and 
■feskiilar respira:: 1 Ii^ stndy, Koweyer, of tKe anscnltatory 
•jitemsmeBi^ in ^ne :.: -. 1^ Ti^TH'^d. is of mneii interest and impor- 
tamfie^ not 011I7 :_ . , . 7 . '-:. zie conversant witK tKe sonnds 

pvfvper to tliose portions of tKe cKest, but bec-anse tKey fnmish 
^pes of pliem!f?inien;a iimdent to disease in otKer situations. It 
win lie seen, bezeafker, tliat the diS^reiit grades of wKat is distin* 
gnidhedis Ae nssnal Immeidal lesfnration, -vvKen present in portions ;| 



AUSCULTATION IN HEALTH. 141 

of the chest other than the points where they belong in health, may 
constitute significant indications of morbid conditions. The student, 
therefore, by impressing on the memory, and verifying by practice 
on healthy individuals, the characters and diversities which belong 
to the normal bronchial respiration, is acquiring knowledge which 
will be directly available in diagnosis. The previous study of the 
tracheal respiration will prepare for that of the bronchial, the two 
being, as will be perceived, analogous, and often, if not generally, 
essentially identical. 

Directing attention first to the anterior surface of the chest, if the 
ear be applied near the sterno-clavicular junction, a respiratory 
sound, differing in several important features from that heard over 
the remainder of the chest (vesicular respiration), is heard in the 
vast majority of cases. To indicate the several points of difference 
would require an anticipation of the description of the vesicular respi- 
ration. The two kinds of respiration will be fully contrasted when 
the latter is considered. But in describing the former it will be ne- 
cessary to imply knowledge of the fact that the bronchial, as well as 
the tracheal respiration, differs from the vesicular in a tubularity of 
character, as distinguished from what will be called a vesicular quality, 
and in greater altitude of pitch. Other distinctive traits need not 
now be alluded to. The following account will be based in part on 
examinations of twenty-three persons in health, made several years 
ago, in order to study the characters of the normal bronchial respira- 
tion ; and more especially on another series of twenty-four exami- 
nations made recently for the same purpose. In both series the 
memoranda were noted at the instant of observation, and the facts 
afterward analyzed. 

In almost every instance a bronchial sound of respiration was dis- 
coverable, both in front and behind, at the points mentioned,^ on 
both sides of the chest. In several instances^ a respiratory sound 
was either absent or scarcely appreciable, except when the force of 
breathing was voluntarily increased, and in the degree of intensity 
marked difference existed in different persons. It was not appre- 
ciable with the cylinder in all instances in which it was discoverable, 
and even well developed, by employing immediate auscultation,^ a fact 

' Absent in 7 of 47 cases in front, and 2 of 36 cases behind. These 9 cases all are 
within the first series of examinations. By employing Cammann's stethoscope a sound 
could probably have been discovered in every instance. These examinations were 
made before that stethoscope was invented. 

2 Six of '24 cases in front, and 9 of 22 cases behind. 

^ This fact was noted as follows : In front, of 24 cases, on both sides of the chest, in 



142. PHYSICAL EXPLOBATIO:?? OT THE CHEST. 

■wMdi goes to Blio"wtliat "b j immediaxe ausctiltatioii tlie traclieal somid 
IB transmitted, since the stethoscope crrcTtmscribeB the space whence the 
sound is conducted, vhile the ear applied directlT to the chest derives 
it from a vider circiiit. In a single instance the sound vas appre- 
ciable "with the cylinder and not 'bj immediate auscnlxation. In two 
iastances it was heard distinctly with Cammann'e instrument, when not 
appreciable either with the ear alone or the ordinary stethoscope. 
In every instance, either in front or behind, in which the broncinal 
respii'ation was compared with that over other parts of the chest, for 
example, the middle of the infra-daTiciilar, and in the infra-scapiilffir 
regions, it was found more or less deficient in the Tesicnlar qxtality, 
in other words approximating to the purely tnhnlar character of the 
tracheal respiration, also xmiformly higher in pitch, and differing 
frequently in other characters.^ 

The bronchial respiration is heard in some persons with both Te- 
spiratory acts, and in some "vdth the inspiration only. In these points 
striking differences are observable. Marked disparities are also 
frequently found to exist between the two sides of the chest in l3ie 
same person. The readiest way to present an idea of these variations 
will be to give, as snccinctly as possible, the result of the analysis of 
the examinations already referred to. Tjinnitrng the analysiB to lite 
twenty-four recent examinations, of this number the bronchial re- 
spiration was heard near the clavicular sternal junction with the act 
of inspiration only, on ioth sides of the chest, in twelve instances, 
leaving the same number of instance in which it was lieard both 
with inspiration and expiration. Behind, in the upper part of the 
interscapular space, of twenty-two examinations, it was heard with 
the inspiration alone, on hath sides, in seven : leaving fifteen instances 
in which it was heard with both respiratoiy acts. According to 
these examinatdons, then, an inspiratory and expiratory bronchial 
sound on both sides of the chest will be found, in front, in the pro- | 
portion of one half, and behind, in the proportion of two-thirds of 
persons free from disease. 

3 cases : on liie right side, 2 cases : on the left side 1 case. Behind, of 22 cases, on both 
sides. 3 cases. 

^ In making this smtement. I am compelled to differ from attthoritiBS on thf snbJEnt 
of physical exploration so distioguished as "Barth and E.c^ex. These "vrriters say (Tiait^ 
Piatique d "Auscultation, etc., 1Bd4. page 33); '"11 ne feudrait pas cxoire que cette 
respiradon bronchique exisre tonjours en c^ points, et se distingue nettement de ia 
respiration des axttres regions : ires-souTent lareiUe la plus exsrc4e ne saisit pas de 
diffirence sensible.'" 



AUSCULTATION IN HEALTH. 143 

As respects this point, the two sides are by no means uniformly in 
correspondence. The inspiratory sound, in a certain proportion of 
cases, is alone heard on one side, while the inspiratory and expiratory 
are heard on the other side. This dissimilarity, however, is subject 
to a rule which, so far as my examinations go, is invariable, viz., a 
sound accompanies both acts of respiration, not infrequently on the 
right side only, and this is never observed on the left side. In 
eight of the twenty-four examinations, a sound accompanied both 
acts on the right side, in front, while an inspiratory sound alone 
existed on the left side. This was true of the back in three of the 
twenty-two examinations ; neither in front, nor behind, did a sound 
with the two acts exist on the left side, and not on the right in a 
single instance. 

It remains to ascertain the results of the analysis as respects other 
characters of the bronchial respiration, and to institute a comparison 
between the two sides, in front and behind, as regards intensity of 
the respiratory sound, disparity in pitch of sound, and the relation 
of the expiration to the inspiration in intensity, duration, and pitch. 
We will direct attention now to these several points. 

Limiting the attention first to the inspiratory sound, in some in- 
stances the intensity appeared equal on the two sides, but in other 
instances a marked disparity was apparent. The enumerations with 
respect to this point are as follows : In front, of ten instances in 
which a disparity of the inspiratory sound was obvious, the intensity 
was greater on the right side in six and on the left side in four. 
Behind, of five instances, the intensity was noted greater on the 
right side in two and on the left side in three. Thus there is no 
rule restricting the existence of greater intensity of the respiratory 
sound to either side ; but, so far as these few observations go, the inten- 
sity is a little oftener greater on the right side in front and on the 
left side behind. The sum total of the instances, in front and behind, 
in which the intensity was greater on the right side, is thus eight ; 
and on the left side seven. These results accord in a striking man- 
ner with those obtained by an analysis of the previous series of ex- 
aminations. Of the latter, the intensity was greater on the right 
side in five of nine instances, and on the left side in four.^ 

Comparing the inspiratory sound on the two sides as regards pitch, 
in a few instances it is noted that no difference was apparent, but in 

' See Prize Essay on Variations of Pitch, etc, Transactions of Am. Med. Association, 
vol. v., page 84, et seq. 



14A: PHYSICAL EXPLOEATIO^' OF THE CHEST. 

a large proportion a disparity was obvious. A fixed rnle evidently 
goyems tliia disparity : of twenty instances in which it was observed 
near the stemo-clavicnlar junction, in nineteen the pitch was higher 
on the risht side, and in a single instance only on the left side. At | 
the upper part of the interscapular space, in all of nine instances, | 
the pitch was higher on the right side. The results are in accordance j 
with those obtained by the former analysis. The latter developed in : 
twenty examinations, elevation of pitch on the right side in fifteen, ^ 
no difference in this respect being appreciable in the remaining five.^ j 
Practically, then, it may be assumed that a disparity in pitch exists \ 
in the larger proportion of instances, and that the pitch is almost j 
invariably higher on the right side. j 

In tubular character, or in deficiency of vesicular quality, a con- | 
trast was observed between the two sides. In this respect the results j 
show an invariable rule, viz., whenever a disparity exists between I 
the two sides, the greater tubularity of sound is found on the right 
side. This was noted in thirteen instances in front and in three 
behind. 

The foregoing results relate to the inspiratory sound- Directing 
attention secondly to the expiratory, the relative intensity of the 
latter to the former is the first point which suggests itself. In a small 
number of instances, it is noted that the expiration was more intense 
than the inspiration. The number of instances is five ; but it is highly 
probable that attention was not given to this point in all the exami- 
nations. So far as these few observations go, they point to a rule, 
viz., when the intensity of the expiratory, as compared with the 
inspiratory sound, is decidedly greater, and confined to one side, the 
right side is the one presenting this contrast. In all of the five cases 
in which the fact was noted, it was on the right side. 

Comparing the pitch of the expiratory with that of the inspiratory 
sound, the results are more strildng. In a very few instances (three) 
the expiratory sound was lower in pitch than the inspiratory. In 
each of these instances it was observed on the left side. In 
every other instance in which the presence of an expiratory sound 
was noted, it was higher in pitch than the inspiratory. An expira- 
tory sound higher in pitch than the inspiratory, on the right side^ 
was noted in twelve instances, viz., nine in front, and three behind. 
In several instances in which this contrast between the two sounds 
existed on both sides, it is stated to have been much more marked 

' See Prize Easay. 



AUSCULTATION IN HEALTH. 145 

on the right side. The difference in this respect was sometimes very 
striking. 

The expiration was in some instances observed to be longer than 
the inspiration. This was oftener noticed on the right side. And in 
every instance in which attention was directed to the point, a brief 
interval separated the sound of inspiration and expiration. These re- 
sults are in accordance with those obtained by the previous analysis.* 

In view of the foregoing results, the following is a summary of the 
descriptive facts and distinctive characters pertaining to the normal 
bronchial respiration, as heard at the sterno-clavicular junction in 
front, and the upper part of the interscapular space behind. In most 
persons a respiratory sound may be discovered and studied in these 
situations, if the force of respiration be increased, by auscultating 
with the ordinary stethoscope ; in a still larger number this is practi- 
cable by immediate auscultation, and in nearly every individual, pro- 
bably, by means of Cammann's instrument ; of a given number of 
individuals, in one-half we may expect to hear an inspiratory and 
expiratory sound in front ; and in two-thirds behind. When a sound 
with both respiratory acts is found on one side, and not on the other, 
it is invariably on the right side. When there is a difference of 
intensity in the respiratory sound between the two sides, the greater 
degree of intensity is found sometimes on the right, and sometimes 
on the left side, the proportion of instances being not far from equal. 
The pitch of the inspiratory sound is generally greater on the right 
side, and almost never on the left side. In some instances also the in- 
spiratory sound is more tubular in character on the right than on the 
left side. The reverse of this is not observed. The expiratory sound 
is sometimes more intense than the inspiratory. When this is more 
marked on one side than on the other, it is on the right side. The 
same remark will apply to prolonged expiration. The pitch of the 
expiratory, as compared with the inspiratory sound, is higher. To 
this rule there are occasional exceptions, occurring only on the left 
side. A striking contrast between the two sounds in pitch is cha- 
racteristic of the bronchial respiration of the right side. When the 
sounds are heard with the two respiratory acts, a brief interval occurs 
between them. 

These facts are interesting and important to the student of physical 
exploration, as already stated, in the first place showing that the phe- 
nomena found at certain portions of the chest in health, together with 

' Prize Essay. 
10 



146 PHYSICAL EXPLORATION OF THE CHEST. 

the variations and the disparity between the two sides of the chest in 
these portions, which are not to be considered evidences of disease ; 
and, in the second place, exemplifying in the healthy chest the 
varieties of the bronchial respiration so-called, occurring as the signs 
of morbid conditions. In the latter respect it will come up for con- 
sideration under the head of Auscultation in Disease. 

On reviewing the elementary characters of the normal bronchial 
and the tracheal respiration, and instituting a comparison between 
them, it will be perceived that in the more important of these cha- 
racters they bear to each other a close resemblance. Both are de- 
ficient, but the tracheal more completely, in a peculiar distinctive 
quality, which will presently be seen to characterize the vesicular 
respiration. Both are high in pitch compared with the vesicular 
respiration. The expiratory sound in each (with a very few excep- 
tions in the case of the bronchial respiration on the left side), is higher 
in pitch than the inspiratory. Frequently in the bronchial, as in the 
tracheal, the expiratory sound is more intense and longer ; and an 
interval separates the two sounds in both cases. The chief points of 
difference are the greater intensity of the tracheal sound, its purely 
tubular character, and the constant presence of an expiratory sound. 

As already remarked, it may be doubted whether the normal bron- 
chial respiration is exclusively bronchial, ^. e, produced solely within 
the bronchial tubes ; but it is a combination of a bronchial sound 
with the tracheal, modified more or less by the vesicular respiration. 
The sound frequently appears to come from a distance. This was 
noted in several of the examinations, especially with respect to the 
expiratory sound. The loud expiratory sound is probably derived 
chiefly from the trachea. On the other hand, the want of complete 
tubularity, greater in some instances than in others, may be attribu- 
table to an admixture of sound from the proximate air-vesicles. 

3. Yesicular Eespiration. — The sound incident to respiration 
heard over the chest elsewhere than upon the upper part of the 
sternum, at the sterno-clavicular junction, and in the upper part of 
the interscapular space near the spinal column, is called the pulmo- 
nary or vesicular respiration or murmur. Both terms imply that 
the sound is produced within the air-cells or vesicles of the lungs. 
This is not strictly true. The vesicular respiration is a mixed 
sound, being partly due to the air entering the cells, in part to the 
current traversing the bronchial tubes, and to some extent, pro- 
bably, in certain parts of the chest, to transmitted tracheal respi- 



AUSCULTATION IN HEALTH. 147 

ration. It is, however, true, that the predominant and distinguish- 
ing character of the vesicular respiration originates within the vesi- 
cles and capillary tubes. The expressions are therefore sufficiently 
appropriate, and the term vesicular is selected as the most dis- 
tinctive, and the one generally adopted. This appellation originated 
with Andral. 

In treating of the vesicular respiration, the facts of interest and 
importance in a practical point of view, will be found to relate mainly 
to 1. The characters which distinguish this variety of respiration 
from the tracheal and bronchial ; 2. The variations in characters 
within the limits of health observed in different persons, and on 
examinations of corresponding situations on the two sides of the chest 
in the same person ; 3. The different modifications presented in 
different regions on the same side. 

The point first claiming attention is the first of the foregoing three 
divisions, viz., ' The characters which distinguish this variety of 
respiration from the tracheal and bronchial.' In considering this 
point, inasmuch as the vesicular respiration in every part of the 
chest is not in all respects identical, some region is to be selected as 
furnishing a type of this species of respiration. The region most 
convenient for this purpose is the summit of the left lung a little 
below the clavicle, midway between the acromial and sternal extremi- 
ties. We will proceed, then, to institute a comparison between the 
characters of the vesicular respiration in the situation just mentioned, 
and those pertaining to the tracheal respiration. The tracheal 
respiration is selected in preference to the bronchial for the compa- 
rison, because, the contrast being stronger, the distinctive traits of 
the vesicular respiration are exhibited in bolder relief, and thereby 
rendered more clear and impressive. 

On auscultating the summit of the left side, at the point mentioned, 
either immediately, or with the stethoscope, a sound more or less 
intense is generally found to accompany the inspiratory act. Com- 
paring this sound with that heard over the trachea, it is found to 
present a striking difference in quality/. Instead of being tubular, it 
has a quality difficult to describe, but which the student will readily 
appreciate on making the comparison practically. The words soft, 
breezy, expansive, are applied to it. It is compared to the slightly 
audible breathing heard at a little distance from a person in deep 
quiet sleep ; to the sound produced by a gentle breeze among the 
branches and leaves of trees ; to that of a pair of bellows the valve of 



148 PHYSICAL EXPLORATION OF THE CHEST. 

which acts noiselessly ; to softly sipping the air with the lips, etc. 
These comparisons are but rudely approximative, and are of little 
value, since it is so easy to become familiar with the sound itself by 
practising auscultation for a few moments on the chest and trachea, 
alternately, of a healthy person, in whom the vesicular respiration is 
tolerably developed. This special quality it is convenient to designate 
the vesicular quality, an expression which will be frequently used in 
the following pages. The vesicular quality of respiration, as of per- 
cussion, is that peculiar kind of sound, not suggesting a priori to the 
mind the existence of cells, but due in a great measure, at least, to 
the cellular construction of the lungs. In what manner is this vesi- 
cular quality of sound generated ? I shall not discuss this, more than 
other questions relating to the physical mechanism by which auscul- 
tatory phenomena are produced. It is generally attributed, after 
Laennec, to the friction and vibrations caused by the air driven into 
the cells by the inspiratory act. May not the peculiar quality be 
owing to the separation of the walls of the cells and capillary tubes, 
which, to a greater or less extent, come into contact, and, owing to 
the moisture of the tissues, are slightly adherent during the collapse 
of the lung incident to expiration ? We shall see hereafter that this 
is the most rational explanation of an important and highly distinctive 
physical sign of disease. Whatever be the rationale, the distinctive 
quality of the vesicular respiration belongs to the inspiratory, and 
not to the expiratory sound. 

The inspiratory sound is somewhat longer in duration than the 
tracheal. Like the tracheal it is continuous, augmenting in intensity 
from its commencement to its termination, and ending rather abruptly. 
It is decidedly lower in pitch than the tracheal inspiration. 

According to Skoda, the average pitch of the vesicular inspiration 
may be represented by the consonant v or 5, whispered. 

In a certain proportion of instances, an expiratory sound is appre- 
ciable. This was the case in fifteen of twenty -four examinations ; no 
sound of expiration being discovered in the remaining nine instances. 
In this respect the vesicular respiration presents a striking point of 
contrast with the tracheal, the act of expiration constantly developing 
a sound within the trachea. The difference is not less striking in 
other respects. The expiration, when present in the vesicular respi- 
ration, is nearly or quite continuous with the sound of inspiration ; 
not succeeding after a brief, but distinct interval, as in the tracheal 
respiration. This statement holds good, except when the person 



AUSCULTATION IN HEALTH. 149 

examined, increasing voluntarily the force of tlie respiratory move- 
ments, holds the breath for an instant after completing the act of 
inspiration. The duration of the expiratory sound, considered 
relatively to that of the inspiratory, is much shorter than in the 
tracheal respiration. In the latter it is as long and not unfrequently 
longer than the sound of inspiration. In the vesicular respiration 
the expiratory sound is estimated by Fournet to average one-fifth the 
duration of the inspiratory. This estimate is perhaps not far from 
the truth,^ but the relative duration varies considerably in different 
persons, in some being less than a fifth, in others a quarter, a 
half, and occasionally, but very rarely, except as an effect of disease, 
bearing a still larger ratio. The intensity, as compared with that of 
the inspiration, is much less. According to Fournet, numerically 
expressed, it is as much below that of the inspiration, as the duration 
is less, viz., one-fifth. The reverse of this rule obtains in the tracheal 
respiration. The pitch of the expiratory sound on the left side, cer- 
tainly in the great majority of instances, is lower than that of the in- 
spiratory. It is represented, according to Skoda, by a sound falling 
between the whispered consonants / and h. Here, too, the rule is 
the reverse of that which governs the tracheal respiration. In the 
latter, the pitch of the expiratory sound is usually higher than that of 
the inspiratory. 

These, then, are the several points of contrast between the tracheal 
and the vesicular respiration; and it is to be borne in mind that 
precisely the same points of contrast exist between the vesicular and 
the bronchial respiration, the only difference being that in the latter 
case they are exhibited in a less striking degree. To recapitulate : the 
distinctive characters of the tracheal and the bronchial respiration on 
the one hand, and of the vesicular respiration on the other hand, as 
developed by the comparison just made, arranged in parallel columns 
are as follows ; 

Tracheal and Bronchial ^Respiration. Vesicular Respiration. 

Inspiration. Inspiration. 

1. Tubular in quality. 1. Vesicular in quality. 

2. In duration falling somewhat short of 2. Longer in duration, 
the inspiratory act. 

3. High in pitch. 3. Low in pitch. 



* Barth and Roger and Walshe make the average duration greater, viz., one-third that 
of the inspiration. The mean duration might be obtained with accuracy, but it is not a 
matter of practical moment. 



150 PHYSICAL explo:ratiof or tbh cehbil 

JEspiration. Mognraiioti. 

1. TJnifarmiy present in traciieal respira- 1. Absent in atoiit Di»-liuTd of the 

2. Generally more intense than the inspi- 2. Imssnsity muchis^ than that of the 
ration. inspiration. 

3. As long or ionsreT than the sound of 3. Much shorter than the sound of iii- 
inspiration. spiration. 

4. Higher in pitch than the inspiration. 4. I^rwer in pitch than the inspiration. 

5. The inspiration and expiration sepa- 5. The inspiration and espiration cnnti- 
lated by an interval. nuouB. 

As already stated, the foregoing points of conr- "' '-' ^' - "^"uMe 
to anscnltation in disease, for in connection "with c 7 ._ _ ii- 

ditions, it toII he f onnd that the Tesicnlar respiration grves piaoe *» 
the tracheal or bronchial, and the latter then Ijeeome physical mgim 
of these morhid conditions. 

The TefflcnLar respiration presents marked differences in diflferent 
persons, not only of the same age and sex, hmt igogsBrently "vdth cheste 
similar in conformation. Tliis statement is app^siSe not alone to 
the respiratory Bonnds pertaining to tiie summit of l3ie left side, Init 
to the thoracic regions in general In intensity it is very JEbct from 
heiag nniform. In some persons it is "with difficulty appreciahle, amd 
in some cannot he heard even "when "the force of the respiration is 
"rdhmtarLly increased. In otiiers it is londly develop^ Meim&m. 
these extremes there is eTery grade of ii>*^i>?7ty. In "the BRme y'sreBa 
the munmir often differs considerahl^ _i _l '^'^=:ty "with different respi- 
rations, "witii some heing perhaps fnll and loud, "while "with others it ffi 
feehle, and sometimes inappreciable, these fiuctnations beinr -''-^— ed 
in the space of the fe-w moments that the ear k applied tc __ _ t r.t. 
In pitch and quality of sound the respirations in the same person appear 
to l>e identical "whether feeble or intense; rr" -^^r::' -r— — --z;^ 
compared "with tranquil breathing, do not sho"w li ^ _ i . : . i 

increased intensi^* It is ieard "with greater intensity by mime :_ 
than by mediate auscultation, pro"rided the ordinai-y cylinder h^ em- 
ployed ; but "with Cammann's stethoscope, the intensity is much greater 
"than "when the ear is placed in direct apposition to tiie chesi I 
may be distinctiy appreciated "with Cammann's stethoscope, "when ii 
is not heard "with the ordinary cylinder or the naked ear. The expi- 
ratory sound, "wMch, as has been seen, is present in some persons and 
absent in others, varying also in its relative dui-:- l _ -'.les 

discovered by immediate auscultation, -when it is :l.; _-„:_ "_„ .ne 
cylinder ; and in some instances miay be rendered distinct Idj Cam- 



AUSCULTATION IN HEALTH. 151 

manri's instrument, wlienit is inappreciable by the ordinary stethoscope 
or the ear alone. My recorded examinations of healthy chests con- 
tain illustrations of these facts. Sex and age exert a decided influ- 
ence on the intensity of the vesicular respiration. In early life the 
intensity is marked, so that a morbidly intense vesicular murmur, 
after Laennec, is frequently distinguished as puerile respiration. In 
old age, on the other hand, the intensity is diminished, a change 
to be attributed, according to Andral, to the attenuation of the walls 
of the air-cells which attends advanced years. At the same time the 
expiratory sound becomes relatively more developed and longer. 
The respiration thus modified by age is distinguished as senile respi- 
ration. In females, as a general remark, the respiratory sounds are 
more intense than in males. This is true more especially of the 
vesicular respiration at the summit of the chest. 

In other respects than intensity, differences are to be observed in 
the respiratory sounds in different persons. The degree of vesicular 
quality and the pitch are not uniform. Auscultating a number of 
persons in succession, in no two perhaps will the murmur, as regards 
these characters, be identical. 

These diversities do not impair the usefulness of auscultation, more 
than a similar want of uniformity in the phenomena developed by 
percussion affects the latter method of exploration ; because in both 
instances, deviations from health are not determined by reference to 
any fixed, abstract standard, as regards intensity, pitch, etc., but, 
generally, by a comparison of the two sides of the chest. 

The expiratory sound, as already intimated, differs from the inspi- 
ratory not only in duration, intensity, and pitch, but in quality. It 
is devoid of the vesicular quality which characterizes the inspiratory 
sound, and is feebly tubular or blowing, resembling the tracheal in 
quality, but differing in its want of intensity and lowness of pitch. 
It remains to consider the variations in characters of the vesicular 
respiration observed on comparative examinations of corresponding 
situations on the two sides of the chest in the same person ; and the 
different modifications presented in different regions on the same side. 

Comparing first the two sides, the summit of the chest claims 
attention more especially, because slight deviations from correspon- 
dence in this situation are of great importance in their bearing on 
the diagnosis of tuberculous disease ; and, moreover, anatomically, 
there is greater equality at the upper part of the chest, than at the 
middle or lower portion, in consequence of the presence of the heart 



152 PHYSICAL EXPLORATION OF THE CHEST. 

and otiier organs, wMch encroach more or less on the thoracic space, 
rendering the two sides more or less unequal. Besides, the diseases 
seated in the lower and middle portions, pneumonia, pleurisy, etc., 
do not generally require so nice a comparison of the two sides as is 
frequently inYolved in the diagnosis of tuberculous disease, which 
affects by preference the superior part of the lungs. For the reasons 
just stated, the question in how far the two sides of the chest are in 
unison as respects the phenomena developed by auscultation, has xa 
important practical relation, and it is highly desirable to determine 
what points of disparity may occur in this situation within the limits 
of health, in order that they may not be mistaken for the signs of 
disease. It is stated by Fournet as a conclusion based on repeated 
examinations of the chest in persons apparently free from thoracic 
disease, that the respiratory sounds at the summit on the two sides 
are absolutely identical, and hence, that any disparity is a just ground 
for assuming the existence of disease.-^ The obseryations of others 
have shown this conclusion to be erroneous. Dr. Gerhard,^ of Phila- 
delphia, was the first to direct attention to the frequent existence of 
disparity between the two sides, consisting, according to him, in a 
crreater intensity of the respiratory sound on the right side, which he 
attributed to the larger size and relative shortness of the right pri- 
mary bronchus. Subsequently M. Louis, in a series of examinations 
of persons free from pulmonary disease, found a certain proportion 
of instances in which an expiratory sound exists on the right side 
and not on the left ; and that when it exists on both sides it is often 
more intense and prolonged on the right side. In the twenty-four 
examinations to which I have already referred, attention was paid, 
among other points, to the one under consideration ; and an analysis 
of the phenomena recorded at the instant of observation, shows dif- 
ferences between the two sides of the summit in intensity, the amount 

* " J'ai clioiii. dans des salles de militaiies ceux qui avaient toutes les apparences de la 
sante la plus robnste, et qni avaient et6 amends i Itopital par des maladies tont-i-fait 
etrangeres axes, organes thoraciqaes ; j'ai bien constat^ chez eux qu'en effet, dans I'^tat 
normal, les braits respiratoires se faisaient entendre absoltiment ^gaux de Yxm. et de 
Tautre cot^. Il resulte de li que toutes lesfois guune difference existera erUre les iruiis des 
deux sommet$ de la poitrine^ cette difference powrra^ en rlglegenerale^ ^re attribvie d une itai 
pathologique.'^' — Recherches sur VJaiscuUation^ etc. t. 1, p. 64. The italics are the anther's. 
Walshe also says, " The characters of the inspiration-sonnd do not differ in the corre- 
sponding points of the two sides of the chest to any appreciable amounL" Ed. of IS 54, 
page 93; Enghsh Ed. 

* The Diagnosis, Pathology, and Treatment of the Diseases of the Chest, by W. "W. 
Gerhard, M J)., etc., 1846. 



AUSCULTATION IN HEALTH. 153 

of the vesicular quality, and the pitch of the inspiratory sound, as 
well as in the relative development, duration, and pitch of the sound 
of expiration. The results of the analysis are as follows : 

1. Inspiratory Sound. — In sixteen of twenty-four cases, more or 
less difference as respects intensity between the two sides was appre- 
ciable. In all but one of these sixteen instances the inspiratory sound 
was more intense on the left side. This result is in direct opposition 
to the statements of some authors ;^ but the matter is purely one of 
observation, and as the comparisons were made with care, and with 
no expectation of ariving at such a result, I am bound to assume 
its correctness. I can only account for the opinion of observers 
that the inspiratory sound on the right side is frequently more intense 
than that of the left, by supposing that elevation of pitch has been 
mistaken for increased intensity. The disparity in intensity was in 
some instances very marked. An inspiratory murmur was occasion- 
ally tolerably developed on the left side, and scarcely audible on the 
right. A striking difference was also in some cases observed in the 
effect of forced respiration on the intensity of the inspiratory sound, 
the intensity on the left side being proportionately increased, without 
any augmentation on the right side. 

In the relative amount of vesicular quality a difference was appre- 
ciable in a large proportion of the cases. And in all the instances 
in which a disparity in this particular existed, the greater amount of 
vesicular quality was on the left side. This was true in fourteen of 
twenty-four examinations of different individuals. The disparity in 
some instances was slight, but in several strongly marked ; in not 
one instance was the vesicular quality greater on the right side. 

Compared as respects the pitch of the inspiratory sounds, a differ- 
ence was apparent in a large majority of the observations. Exclud- 
ing a few cases in which attention was not directed to this point, of 
nineteen examinations, the pitch was higher on the right side in 
twelve, and no disparity was appreciable in seven ; in not a single in- 
stance was the pitch higher on the left side. The difference here as 
with respect to the preceding characters, was in some instances 
striking, and in other instances slight. This numerical result does 
not vary much from that obtained by an analysis of the series of 
previous examinations. The latter numbered fifteen, and of these 
fifteen examinations the inspiratory murmur was higher in pitch 

' Gerhard, Earth and Roger. 



154 PHYSICAL EXPLORATION OF THE CHEST. 

on the riglit side in eleven, and no disparity was observed in the 
remaining four. 

So far as the data just presented, then, furnish ground for deduc- 
tions, a disparity between the inspiratory sounds at the summit of 
the chest in front, exists in a large proportion of individuals free from 
all symptoms of thoracic disease, this disparity pertaining to the inten- 
sity, vesicular quality, and pitch. Variations in these three charac- 
ters obey certain rules, viz., the greater relative intensity is almost 
uniformly on the left side. The same rule holds good with respect 
to a greater relative amount of the vesicular quality. On the other 
hand the greater elevation of pitch is always on the right side.-^ 

2. Expiratory Sound. — Facts relative to the intensity of the ex- 
piratory sound on the two sides are contained in the notes of nine 
examinations. Of these nine comparisons, in three instances an ex- 
piratory sound was appreciable on the right side, and none on the 
left side ; in two the development on the right side was greater than 
on the left, and in thi-ee, the intensity seemed equal on the two sides. 

In several instances the expiratory sound on the right side was 
prolonged, sometimes being nearly or even quite as long as the inspi- 
ratory ; on the contrary the expiratory sound, when present on the 
left side, was always short, never exceeding one-third of the duration 
of the inspiratory. It is noted in several instances that the expira- 
tory sounds on the right side seemed distant from the ear. 

In several instances, on the right side, a brief interval separated 
the sounds of inspiration and expiration. In every instance, on the 
other hand, on the left side, the two sounds were continuous. 

The pitch of the expiratory sound was higher than that of the I 
inspiratory on the right side in eleven instances, and on the left side 
in a single instance. It was lower on the left side in six, and on both 
sides in four instances. 

According to the foregoing results, an expiratory sound exists on | 
the right side in a certain proportion of cases in which none is appre- 
ciable on the left side. It is frequently prolonged on the right side, 
appears distant, and is separated from the inspiratory sound by an 
interval, and is higher in pitch. 

The facts presented in the foregoing comparative account of the 
summit of the chest in front, may be seen at a glance by reference 
to the subjoined table. 

* The relative duration of the inspiratory sound on the two sides is another point of 
comparison, to which attention was not directed in making the examinations. 



AUSCULTATION IN HEALTH. 155 

Comparison of Right and Left Infra-clavicular Regions. Whole number of 
examinations twenty four. 

Inspiratory Sound. 

Eight. Left. 

I Greater intensity in 1 case. Greater intensity in 15 cases. 

I Vesicular quality more marked in no Vesicular quality more marked in 14 

j case, cases. 

I Higher pitch of sound in 12 of 19 exami- Higher pitch of sound in no case. 
I nations. 

' Expiratory Sound. 

j Right. Left. 

' Present on this side, and not on left side, Present on this side, and not on right side, 

in 3 cases. in no case. 

More intense on this side in 2 cases. More intense on this side in no case. 

Prolonged in several cases. Prolonged in none. 

An interval between the sounds of in- The two sounds continuous, 
spiration and expiration in several cases. 

Pitch higher than that of the inspiratory Pitch higher in 1 instance, 
I sound in 11 instances. 

j Pitch lower than that of inspiration in 4 Pitch lower in 10 instances. 
i instances. 

Eeviewing the facts pertaining to both the inspiratory and the 
expiratory sound, it is perceived that the several elements which 
have been seen to compose the bronchial respiration are manifested 
at the summit of the chest, in front, on the right side. This is a 
practical conclusion arrived at by means of the foregoing analysis. 
Assuming this conclusion to be correct, its importance will be appa- 
rent hereafter, in connection with the diagnosis of tuberculosis of the 
lungs in the early stage. In that connection, without knowledge of 
the facts which have been presented, it can hardly be otherwise than 
that error of diagnosis will be committed, by mistaking for the 
physical signs of disease, the several characters of the bronchial 
respiration which may exist at the summit of the right chest, not pro- 
ceeding from a morbid condition. I am free to state that my own 
experience would supply illustrations of error from this source. 

The post-clavieular region may be examined by auscultation, the 
stethoscope being requisite in this situation. The caution inculcated 
by Laennec, is important to be borne in mind in applying the stetho- 
scope above the clavicle, viz., to avoid pressing the instrument in a 
direction toward the trachea. The tracheal sounds are liable to be 
conducted to the ear if attention be not paid to this point. Pressure 
of the stethoscope in this region may develope an arterial bruit which 



156 PHYSICAL ZZJl-^-I : - z^^ :-^5T. 



_::"- .:- :".:.■ ^ . r : - i _ .-- ^Ij 

'_ ^ :. — :_. ::":;;. :i -^ ■,.;;! . = :_:...' ''^ :r:-:eet 

:; : "_ . — : :!. —. -'^^ I - r^r _ - ls. ' In 

" --r- ----- -- "--:- --; ------ 7-^ - ; ^ ^^^ 

-::jt_ l:" :: ::. :--ir ".. r ^:t:_; ; ; ;- t - ;-; : -„- ■; :_ : _. _„ _ra- 

:;:7 : ; vi - : , : _.'t:_^t 1 rlr _.i of expira- 

t: ::, 7 -::::: ^ T . ^ _. " . ' : _ _ : . . _ : . -' i' terral, 

a ~:1-- -t1 tZ_ __ : _7 : :_7 -_:_„:.- : _ ^ . higher 

in pit^i. 

Fisssiii^ next;, to the xq^per ponion of liie chesi beinnd, oTei ine 
«e«^wl<(K a&i9Pe £^ spimmiM ridge^ owing to the ££lciillj <£ appl jing 
the ear direedj, tlie steAoeeope is prrfo&ble. With tlie wooden 
ejiinder a le^ratoiy eonnd is heard Bofliqentily to stadj its ^la- 
raetets and institolje a ocHnpaziscRi between die two eides in (Hihr a 
eertain pt^oslion of eases. Widi Gammann's instrument it is some- 
times rendexed dstinet when it is scarcely ap^eciable witk the ordi- 
naiy stedioeoope. This insimmeiit ^as n'^pd \sj me heze, as in other 

ataadons, in hot a pcnlian of ile - 7 :: 3ns made widi a Tiew t» 

Etody the phenomena inadTi: health. TheiesaltB 

devidoped bj the anat^^ : : -^^li probaldj bare 

been to scmie ext^it diSferei ^ r^plojed in oon- 

jnnedon wilb immediate : _ :lie irooden 

ejiinder. 13ie fiuds pe^ , " inds in the 

uppo* se^^alar regifm on :_ ." ^ ._ tventy-one 

examinationfi are exhibited in tiie folkywn 2 : t : 



J 



Gmpaiaamof BigktaMlI^JJi 



'J:^ 



bodtadesmS 



ScsEod iiMli^liHraly ^ppsscsak^ in 7 in- 





m 1 CBse <s 7, m wM^k Ba£e:2^tT r: 
near Ibsb duvtJijped liy 






AUSCULTATION IN HEALTH. 157 



I Expiration. 
Right. Left 

Expiratory sound, absent in 7 cases. Expiratory sound absent in 10 cases. 

Indistinctly appreciable in 4 cases. Indistinctly appreciable in 5 cases. 

Prolonged in 5 out of 6 examinations Prolonged in no case. 
made with respect to this point. 

More intense than the sound of inspira- More intense than sound of inspiration 

tion, and higher in pitch in 5 cases. and higher in pitch in 1 case.' 

It follows from these results that "wMle an inspiratory sound is 
absent on both sides in an equal proportion of cases, viz., about one- 
third, the sound of expiration is oftener absent on the left than on 
the right side ; both the inspiratory and expiratory sounds are oftener 
very feeble on the left side, but when tolerably developed the inspi- 
ratory sound on the left side is apt to be more vesicular and more 
intense than on the right, while the latter is apt to be higher in pitch ; 
and the sound of expiration on the right side in a certain proportion 
of instances is prolonged, more intense than the inspiratory, and 
higher in pitch, this being very rarely the case on the left side. Ac- 
cording to these results the disparity frequently existing between the 
two sides, corresponds with that observed at the summit and in front. 
More or less of the elements of the bronchial respiration, in other 
words, are occasionally manifested on the right side. 

The respiratory sounds when heard over the upper scapular region 
are not only less intense than in front of the summit of the chest, 
but the vesicular quality is less marked, and they convey to the mind 
the impression of greater distance from the ear. 

In examining the scapular region helotv the spinous ridge, imme- 
diate auscultation is available. A respiratory sound is appreciable 
here in a larger number of instances than above the ridge, and is 
more intense when present in both situations. It is, however, consi- 
derably less intense in the cases in which it is fully developed than in 
the infra-clavicular region. Here, also, as above the spinous ridge, 
the vesicular quality is less marked, and the sound seems farther 
removed from the ear. An analysis of the observations recorded 
with reference to a comparison of the two sides gives the results exhi- 
bited in the following table : 

' In this case the contrast with the inspiration in these respects, was less than on 
the right side in the same case. 









Tg^.. 



jvdiea JCi-sarer ir. p^::^ _L^- - - .^ - - : :n_ ^-'« r:i __ _.^i:_ __; :;: — -ruiBitS 



fables. The insMFi - le inteiirr i hmwc 



.^. 



on file lei: .-:_:_ 

serfaUe,ii; is lu^icr . _^ ^ _i' 

€n At . _ _ _ 1 : ' 1 : _ r . 7 r: sid&. ISie rewerse is 



Ifcis tlieaoaidi^ 

ontiiei^kts l liie 1e£t ade. It 



.:_:_.'_ T f ^ :_;::: n on fiie r^^ 
Ais does r ^ 1 _ - 1 tT liand, it 

_;;:;_._:- ;:;. :_t t : : fA^ and 



laidhf on f^ li^hl 
fiietvo sides as icg^2 



dTffaebi 
!l!be difenencieB bt 



AUSCULTATION IN HEALTH. 159 

bable hj the following experiment : The larynx, trachea, and primary 
bronchi, with some of the larger subdivisions of the latter extending an 
equal length on each side, were detached from the pulmonary organs 
and removed from the body. Then by means of a large pair of bellows, 
the nozzle of which was inserted into the larynx and secured by a 
ligature, a current of air was made to traverse the bronchial tubes 
first on one side and afterward on the other side by compressing al- 
ternately the right and the left bronchus with the finger. Compar- 
ing the sounds thus produced, which were quite loud, it was very 
obvious that the sound produced by the current of air driven through 
the right bronchus and its subdivisions was more intense and higher 
in pitch than that produced within the left bronchial tubes ; care 
being taken to place the two bronchi as nearly as possible in their 
natural position as regards their angular relation to the trachea. This 
experiment was repeated numerous times in the presence of several 
medical gentlemen, and also in the lecture room before a large class 
of medical students. The disparity just stated was not less obvious 
to others than to myself. When the current was made to traverse 
the bronchial tubes on both sides simultaneously, it was easy to per- 
ceive a difference in intensity and pitch on bringing the ear in close 
proximity to the bronchial tubes first on one side, and then on the 
other side. 

The result of this experiment may seem at first to be inconsis- 
tent with the fact that the inspiratory sound on the left side is fre- 
quently more intense than that on the right side. It is, however, to 
be borne in mind, that it is the sound produced within the vesicles on 
the left side which is more developed than on the right side. The 
respiration on the left side presents a more marked vesicular quality, 
at the same time that its intensity is in some instances greater. The 
latter, then, it is fair to conclude, is due to some cause connected with 
the air-cells, and not with the bronchial tubes. 

In the infra-scapular region a respiratory sound is almost uni- 
formly appreciable. It is generally well developed, and frequently 
with forced breathing becomes intense. Here, as in other situations, 
a very marked diiference in intensity is often observed between the 
sounds developed by ordinary and forced breathing : with the latter, in 
some instances, they are quite loud, when with the former they may 
be scarcely heard. As a general rule, the intensity is greater than 
in the lower scapular region ; the vesicular quality is also more appa- 
rent, and the pitch somewhat lower. This rule is not without excep- 
tions. The intensity in a small proportion of instances is about equal 



160 PHYSICAL EXPLORATION OF THE CHEST. 

in the scapular and infra-scapular regions ; so, also, the vesicular quality 't 
and pitch. In one of the examinations which I have noted, the in- f 
tensity was in a marked degree greater below, than over the scapula. 
The person examined was a female. 

The subjoined table exhibits the results of a comparison of the two 
sides as respects the respiratory sound observed in this region. 

Comparison of the Eight and Left Infra-scapular Regions. 

Inspikation. 

Present in all of 21 examinations. 
Right. Left. 

More intense in 1 of 14 examinations. More intense in 5 of 14 examinations. 

Vesicular quality more marked in none Vesicular quality more marked in 2 of 
of 11 examinations. 11 examinations. 

Pitch higher in 4 of 13 examinations. Pitch higher in none of 13 examinations. 

Expiration. 
Of 17 examinations present in 5 and absent in 12. 
Right. Left. 

Present only on this side in 1 of 5 cases.* Present only on this side in 1 of 5 cases. 

The variations between the two sides are decidedly less frequent and 
marked in this situation than in the regions before compared. In a 
few instances the intensity is greater on one side, and when this is the 
case, the greater intensity is almost uniformly on the left side. Oc- 
casionally the vesicular quality is more marked on the left side, and 
in a few instances the pitch is higher on the right side. 

The expiratory sound is almost uniformly lower in pitch than the 
sound of inspiration. A single exception to this rule was noted on 
the right side, and in this instance the sound was distant, an intense 
expiratory sound existing over the scapula on the same side. This 
case shows that it is possible for the tracheal or bronchial respiratory 
sounds to be transmitted in the healthy chest to the ear applied 
below the scapula, — a fact important to be remembered, since these 
sounds in that situation in the vast majority of cases is evidence of 
disease. 

Passing to the front of the chest, it wiU suffice to notice the respi- 
ratory phenomena furnished by auscultation in the mammary and 
infra-mammary regions under the same head. 

An inspiratory sound is almost uniformly appreciable in these 
regions, but differing considerably in intensity in different individuals. 

* In this case it is noted that the sound was distant and high in pitch ; an intense 
expiratory sound existed in that case over the scapula. 



AUSCULTATION IN HEALTH. 161 

Of 23 recorded examinations in which more or less of the respiratory 
phenomena were noted, in no instance was an inspiratory sound in- 
appreciable. Instances, however, are occasionally met with. The 
intensity is less than at the summit, with very few exceptions. This 
was true in all but two of sixteen observations made relative to 
this point. In one of these two instances the greater development 
in the mammary region was confined to the right side ; and in the 
other instance the inspiratory sound at the summit was extremely 
feeble. The pitch is uniformly lower. Of eighteen observations this 
was true without an exception. The vesicular quality is, at the same 
time, more marked. The latter, and lowness of pitch, are correlative 
traits. In these three points of view, viz., diminished intensity, 
lowness of pitch, and more marked vesicular quality, the difference 
on comparison with the summit of the chest is sometimes greater on 
one side of the chest than on the other side. This fact is noted in 
several instances. It is to be explained by the disparity which has 
been seen to exist at the summit in a certain proportion of individuals 
as regards intensity, pitch, and vesicular quality. Supposing the 
inspiratory sounds at the middle and lower portions of the chest to be 
equal, a comparison with the sounds at the summit will, of course, 
not give identical results if the two sides at the summit differ. 
Another explanation, applicable to a certain extent in some instances, 
is, that the sounds over the middle and lower portions on the two 
sides are not equal. The latter is true, but of a very small propor- 
tion of cases save with respect to intensity. Of twelve comparisons 
of the two sides, in five the intensity appeared somewhat greater on 
the left, and in two on the right side. With a single exception, in 
which the pitch appeared a little higher on the right side, there was 
no disparity in pitch or vesicular quality between the two sides. In 
the course of my examinations I attempted in several instances to 
determine whether there was an appreciable difference in the pitch, 
intensity, or vesicular quality of the inspiratory sound over the upper 
lobe on the left side, or the middle lobe on the right side, and the 
small portion of the lower lobe extending in front. I endeavored, in 
other words, to define the situation of the interlobar fissure by a 
change in the vesicular murmur. In one instance, and one only, I 
appeared to succeed. In that instance the person was a good subject 
for this experiment, the vesicular respiration being unusually well 
developed. Passing the stethoscope downward on a vertical line 
falling about half an inch within the nipple, on the left side, between 

11 



162 PHYSICAL EXPLORATION OF THE CHEST. 

the fourth and fifth ribs, the characters of the inspiratory sound 
abruptly changed, the pitch especially becoming lower, and the ^ 
intensity lessened. The same abrupt change was discovered on the 
right side. 

An expiratory sound is very rarely appreciable in the mammary 
and infra-mammary regions. Its presence is noted in two only of 
thirteen examinations, the records of which contain information on 
this point. In one of these two cases it was only appreciable with 
Cammann's instrument, not by immediate auscultation, or the ordinary 
stethoscope. The number of instances in which it was appreciable 
would have perhaps been greater had Cammann's instrument been 
employed in a larger proportion of the examinations. It was used in a 
little less than one-half of the cases only. In both instances in which 
an expiratory sound was present, the pitch was distinctly lower than 
that of the inspiratory. 

It is unnecessary to introduce a table exhibiting the results of a ' 
comparison of the two sides of the chest, as respects the respiratory 
phenomena, observed in the mammary and infra-mammary regions, 
for the disparity noted, as has been seen, with a single exception, 
consists in a greater intensity of the vesicular murmur on the left i 
side in a certain proportion of cases, and on the right side in a 3 
smaller proportion. 

In the axillary and infra-axillary regions, an inspiratory sound, 
especially with forced breathing, is often heard with as much and 
even more intensity than over any other part of the chest : of thirteen I 
examinations, in none was the respiratory murmur absent. Its I 
absence, however, in these regions would not necessarily denote disease 
more than in other situations where it is generally present. It may 
be inappreciable in healthy chests, in some instances, for reasons that 
are apparent, as when the thorax is covered with a very thick layer 
of adipose deposit ; and in other instances when no cause is apparent 
and it can only be attributed to a peculiarity of constitution. As in 
other situations the intensity differs considerably in different persons. 
The intensity is generally less in the infra-axillary, than in the 
axillary region, and the pitch somewhat lower. Careful comparison 
of the two sides, according to my observations, shows some points of 
disparity in the larger proportion of cases. Thus, of twelve exami- 
nations, in five no difference was apparent, and in seven there existed 
more or less inequality. The facts respecting the disparity in 
the seven cases in which it was noted, are as follows : the intensity 



AUSCULTATION IN HEALTH. 163 

was greater on the left side in three cases, and on the right side in 
three cases. The pitch was higher in four cases, all on the right side. 
The vesicular quality was more marked in three cases, all on the left 
side. 

An expiratory sound is heard in a much larger proportion of 
instances than over the middle and lower portions of the chest in 
front or behind. Of nine examinations its presence is noted in five, 
and its absence in four. It was present in the axilla in some instances 
and not in the infra-axillary region. It was lower in pitch than the 
inspiratory sound save in one instance, and in this instance it was 
higher on the right side and lower on the left. 

II. PHENOMENA INCIDENT TO THE VOICE. 

The phenomena produced in health by the act of speaking, like 
those incident to respiration, diifer in different portions of the respi- 
ratory apparatus ; and the vocal, as well as breathing sounds may be 
arranged according to their situation, into 1st, those produced within 
the larynx and trachea ; 2d, those heard over the large bronchi ; and 
3d, those emanating from the chest generally. The healthy pheno- 
mena in these several situations incident to the voice, not less than 
those developed by respiration, represent sounds which, by a change 
of place, become the signs of disease. The more important of the 
vocal phenomena pertaining to morbid conditions may, in fact, be 
studied upon the healthy living subject. Moreover, here, as in the 
case of the respiratory phenomena, variations within the limits of 
health exist in different individuals, and in the same individual in cor- 
responding regions of the two sides of the chest, which, without due 
knowledge and care, are liable to be mistaken for the evidences of 
disease, giving rise, possibly, to serious errors of diagnosis. The 
study of the phenomena incident to the voice in health, therefore, 
merits close attention, preparatory to entering on the subject of aus- 
cultation in disease. 

In auscultating for vocal sounds, in health and disease, the ear 
may be applied immediately to the chest, or the stethoscope may be 
employed. In general, the sounds are better appreciated and are 
more intense with the naked ear than with the ordinary stethoscope, 
and the latter is not only useless, but disadvantageous, except when 
it is desired to concentrate the examination upon a circumscribed 
space, or direct it to parts of the chest to which the ear cannot be 
satisfactorily applied. In listening to vocal phenomena with the ear 



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AUSCULTATION IN HEALTH. 165 

are the several elements which compose the mixed sensations embraced 
under the head of the tracheal voice. It will facilitate a clear appre- 
hension of the vocal phenomena incident to the auscultation of dif- 
ferent parts of the respiratory apparatus, and not less to morbid con- 
ditions, to consider the tracheal voice as thus made up of different 
constituents. All these elements, in the great majority of instances, 
will be found to enter into the tracheal voice, the differences in dif- 
ferent individuals consisting in variations in the degree, absolute and 
relative, which they present. The resonance and shock and fremitus 
are generally strong. Of twenty-two examinations it is noted that 
these elements were strongly marked in eighteen ; considerably so in 
three, and moderate in one only. 

These three elements, as a general remark, appear to preserve a 
mutual relation ; that is to say, they participate about equally in the 
variations, as regards intensity, observed in different individuals. 
Yet they do not involve precisely the same physical causes. The 
resonance is due to the reverberation of the voice within the tracheal 
space ; the shock to the force given to the column of air by expira- 
tion in connection with its partial, sudden arrest by the act of 
speaking, and the fremitus to the vibrations of the tracheal tube, in 
conjunction with those of the vocal chords. Collectively, they are 
more strongly marked in proportion to the strength of the voice, and 
its gravity of tone. Hence, in females and children, they are com- 
paratively less prominent. If Cammann's stethoscope be applied over 
the trachea, the shock and resonance are felt with a painful intensity, 
in some instances being quite unendurable; the articulated voice, 
however, is not conducted much better through this instrument than 
through the ordinary cylinder. 

The transmission of sounds more or less perfectly through the 
stethoscope is an interesting and important element of the tracheal 
voice, from the fact that when it occurs over the chest, as incident to 
disease, it constitutes the physical sign called Pectoriloquy. Pecto- 
riloquy is said to be perfect when the articulated sounds are distinctly 
heard with the ear applied to the chest mediately or immmediately. 
It is imperfect when the words- are indistinctly heard. The types of 
perfect, and the various grades of imperfect pectoriloquy, are fur- 
nished by auscultation of the trachea. Hence, by becoming prac- 
tically acquainted with this element of the tracheal voice, the 
student acquires, at the same time, an acquaintance with a morbid 
sign, the significance of which will be hereafter considered. The 



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AUSCULTATION IN HEALTH. 167 

the marked differences, compared with the tracheal, which the student 
is led to expect from the writings of some authors; and in some 
instances^ the sounds in both situations are very nearly if not quite 
identical. As a general rule, the shock and vibration commu- 
nicated to the ear are less than when auscultation is practised over 
the trachea. There are some exceptional instances in which they 
are of the same intensity, but very rarely, if ever, greater. The 
transmission of the articulated voice is oftener perfect, and generally 
less incomplete. Of eighteen comparisons with reference to the 
latter point, in no instance was the pectoriloquous element more 
marked over the trachea ; in six instances there was no obvious dif- 
ference between the tracheal and laryngeal voice in this particular, 
and in twelve instances the transmission was decidedly more complete 
over the larynx. 

2. Bronchial Voice ; Normal Bronchophony. — Applying the 
stethoscope, or the naked ear, to the chest at the points where the 
normal bronchial respiration is to be sought for, viz., in front near 
the sterno-clavicular junction, and behind, in the interscapular space, 
on a line with the spinous ridge of the scapula, the phenomena atten- 
dant on the act of speaking constitute what is distinguished as the 
bronchial voice, or normal bronchophony. It differs greatly from 
the tracheal voice or tracheophony, but the difference consists mainly 
in the characters of the latter being but partially present, and with 
a much less degree of intensity. A certain amount of resonance 
characterizes the bronchial voice, and this varies considerably in its 
intensity in different persons. In some persons it is quite strong, in 
others almost inappreciable, and it may present every grade of inten- 
sity between these extremes. Other things being equal, it is stronger 
in proportion to the power of the voice and gravity of its tone. It is 
better appreciated and its intensity is greater by immediate than by 
mediate auscultation. It is rarely, if ever, the case that the ear re- 
ceives a shock or concussion, such as is felt when the stethoscope is 
placed over the trachea. A fremitus or thrill is either absent, or, if 
present, is generally slight ; but in some instances it is well-marked. 
The articulated voice is very rarely transmitted. Whispering pecto- 
riloquy exists in a small proportion of cases. The results of an ana- 
lysis of fifteen observations relative to the transmission of the voice 
are, that in nine instances pectoriloquy, perfect or imperfect, did not 
exist ; in but one instance were spoken words conveyed to the ear, 



168 PHYSICAL EXPLOKATION OF THE CHEST. 

and in this instance in the interscapular space only ; in two instances 
■whispering pectoriloquy was perfect, and in three instances imperfect. 
A souffle or blowing sound was observed in some instances to accom- 
pany the utterance of words spoken aloud, and in a large proportion of 
instances whispered words. These, then, are the characters of normal 
bronchophony contrasted with tracheophony : A resonance less in 
degree, and differing widely in different persons ; absence of shock 
or concussion ; a fremitus or thrill present in a certain proportion of 
cases, and less marked ; words spoken aloud transmitted only as an 
occasional exception to the general rule, and whispering pectoriloquy, 
perfect or imperfect, existing in a small number of instances. 

Comparing the two sides of the chest in front and behind, an 
obvious disparity exists in a large majority of cases. This is seen by 
the following table giving the results of a series of observations relative 
to this point : . 

Comparison of the Eight and Left Side of the Chest, as respects Kormal 
Bronchophony. 

Front, 
Right Left. 

Resonance greater in 19 of 23 examina- Resonance greater in none of 23 exami- 
tions. nations. 

Back. 

Right. Left. 

Resonance greater in 13 of 22 examina- Resonance greater in none of 22 exami- 
tions. nations. 

It thus appears that excepting a very small proportion of instances 
the vocal resonance is greater on the right side in front, and in a 
ratio of more than one-half it is greater behind, while a greater 
degree of resonance is never observed on the left side either in front 
or behind. In some instances a resonance exists on the right side 
and none is appreciable on the left. This was observed in two 
instances in front, and in two instances behind. The difference 
between the two sides in the cases in which it was perceived 
on both, was sometimes slight, but in some instances strongly 
marked. It was generally more apparent on immediate auscul- 
tation, than with the ordinary cylinder ; and was rendered still more 
apparent by Cammann's stethoscope. 

3. Normal Vesicular Vocal Resonance. — I adopt the title 
vesicular vocal resonance to distinguish the sound occasioned by the 



AUSCULTATION IN HEALTH. 169 

voice when the ear is applied over the chest elsewhere than at the 
situations where the bronchial voice, as well as the normal bronchial 
respiration, is to be sought for, viz., at the upper part of the intersca- 
pular space behind, and near the sterno-clavicular junction in front. 
The title is to be preferred, not so much from its intrinsic appropriate- 
ness, as for the sake of uniformity, the respiratory sounds heard over 
the chest, with the exception just mentioned, being called vesicular. 
The vocal sounds cannot with strict propriety be called vesicular, 
inasmuch as the air-vesicles have no agency in their production. In 
its present application the term simply denotes that the sound is that 
heard over all those portions of the chest beneath which the air- 
vesicles predominate over the bronchial tubes, obstructing the trans- 
mission of the sonorous vibrations, which may be either conducted by 
the latter from the larynx, or possibly reproduced within them. The 
same objections are applicable equally to the term pulmonary ^ which 
' by some writers is used to distinguish the vesicular respiration. 

The vesicular vocal resonance presents important distinctive traits 
when contrasted with the tracheal or bronchial voice, more especially 
the former ; certain differences are frequently observed when corre- 
sponding regions on the two sides of the chest are compared, and the 
effect produced by the act of speaking in different portions of the 
same side are not identical. The vesicular vocal resonance is to be 
considered under these three points of view. 

First, as contrasted with tracheophony and normal bronchophony, 
the vesicular resonance is generally much weaker ; in other words, it has 
much less intensity. It differs from the former, especially, in not 
being constantly present ; not unfrequently over portions of the chest 
no resonance is appreciable, at least with the ordinary stethoscope, 
and immediate auscultation ; and in some persons it is absent over 
the entire chest. The sound, in general, seems farther removed from 
the ear. It is rarely accompanied by a sense of concussion or shock. 
It is less frequently attended by fremitus or thrill, but in some in- 
stances, in certain parts of the chest, the latter concomitant is 
strongly marked ; and it is sometimes present in a degree which is 
out of proportion to the amount of resonance. Transmission of the 
articulated voice, in other words pectoriloquy, does not occur in con- 
nection with normal vesicular resonance, save as a very rare anomaly. 
Imperfect whispering pectoriloquy is occasionally observed ; and not 
very unfrequently, in some parts of the chest, the act of speaking 
in a whisper occasions a souffle or blowing sound, resembling that 



170 PHYSICAL EXPLORATION OF THE CHEST. 

wMch attends the tracheal and the bronchial voice. These are the 
important points distinguishing the phenomena embraced under the 
appellation of the normal vesicular resonance from those emanating 
more directly from the larynx and trachea, and the larger bronchial 
divisions. 

The vesicular vocal resonance presents in different individuals in 
health, even greater variations in degree than the vesicular respira- 
tion, due to differences in power of voice, gravity of tone, and other 
circumstances not so obvious. There is not, therefore, in the one 
case, more than in the other, a certain normal intensity to be referred 
to as a standard for comparison. In both cases, equally, morbid 
intensity is not determined by reference to an abstract criterion, or 
to an average, but by ascertaining, as far as practicable, the degree 
of resonance natural to the individual ; and this is generally done by I 
instituting a comparison of corresponding situations on the two sides 
of the chest, taking advantage of the laws of disease, in conformity 
with which, happily, for the most part, either it is confined to one 
side, or is more advanced on one side than the other. This rule of 
practice is based on the assumption that in a condition of health, and 
provided the conformation be symmetrical, the two sides of the chest 
furnish the same phenomena on auscultation. Theoretically this may 
be assumed, and as already remarked, it is a fundamental principle I 
in physical exploration. Its importance in diagnosis is made at once 
apparent by this statement, viz., if the two sides are found to be free 
from any disparity as respects the normal phenomena obtained by 
physical exploration, the evidence is conclusive against the existence 
of intra-thoracic disease. But we have seen that, as regards pheno- 
mena incident to respiration, this rule is practically not without fre- 
quent and striking exceptions. The same fact will be found to hold 
good with respect to the phenomena incident to the voice. Hence, 
it is sufficiently obvious that to avoid the error of mistaking normal |> 
differences for the signs of disease, it is highly important to become 
acquainted with the nature and extent of the deviations from equality 
which are liable to occur within the limits of health. Fortunately 
these deviations are found generally to observe certain laws, the 
knowledge of which will secure against error of diagnosis, which would 
be unavoidable if such laws did not exist. Proceeding to consider \ 
the vesicular vocal resonance in corresponding situations on the two 
sides of the chest, and in different parts of the same side, it will be 
convenient to pursue the same course as in treating of the respiratory 



AUSCULTATION IN HEALTH. 171 

phenomena under these points of view, taking up successively the 
more important of the thoracic regions, and giving the results of the 
analysis of a series of examinations of persons presumed to be entirely 
free from any disease of the respiratory apparatus. Directing atten- 
tion first to the summit of the chest, the different regions will be 
noticed in the same order as under the head of vesicular respiration. 
Infra-clavicular region. — Vocal resonance is rarely absent in this 
region. Of twenty-three examinations it was appreciable in all, but 
varying widely in degree, being in some instances slight and scarcely 
appreciable, and in other instances the varied intensity indicated by 
the terms moderate, considerable, strongly marked, etc. A thrill, 
more or less in degree, in some instances accompanied the resonance, 
and was sometimes more marked than the resonance. Pectoriloquy 
did not exist in any instance. Imperfect whispering pectoriloquy is 
noted in one instance. A souffle frequently accompanied whispered 
sounds. The results of a comparison of the two sides of the chest 
are exhibited in the following table : 

Comparison of the Riglit and Left Infra-clavicular Regions. 
Right. Left. 

Vocal resonance greater in 20 of 24 ex- In none of 24 examinations, 
aminations. 

Imperfect whispering pectoriloquy in 1 In no case, 
case. 

Souffle with whispered words confined In no case, 
to or more marked on this side noted in 4 



Greater thrill noted in 2 cases. In no case. 

It thus appears that in a very large proportion of the persons 
examined relatively to this point, viz., in 20 of 24, the vocal reso- 
nance was distinctly greater in the right than in the left infra-clavi- 
cular region ; there being no obvious disparity in the remaining four 
cases. These results are opposed to the opinion of Fournet\ pro- 
fessedly based on numerous observations, viz., that a marked disparity 
in this region between the two sides is evidence of disease. And as 
regards the disparity, a law appears to be invariable, viz., the increased 
resonance is always on the right side. The frequent existence of 
greater resonance on the right side has been well known to practical 
auscultators of late years. The fact was first pointed out by Stokes, 

' Op. cit. page 152, torn. 1. 



172 PHYSICAL EXPLOEATIOX OF THE CHEST. 

and was confirmed by the researches of Louis. ^ It is usually attri- 
buted to the larger size of the right bronchus. 

As regards the amount of disparity noted in the records of the ex- 
aminations, it differed considerably. In a few instances a resonance 
was distinct on the right side, none being appreciable on the left. 
In some instances the difference was slight ; in other instances more 
strongly marked, and occasionally the contrast was striking. 

The comparisons were made in every instance with the ordinary 
stethoscope, and by immediate auscultation ; and in about half the 
examinations Cammann's instrument was used in addition. 

Scapular region. — Tocal resonance is generally more or less 
marked in this region : of tWenty-three observations in no instance 
was there absence of resonance on the two sides. It is habitually 
less in intensity than at the summit of the chest in front. It is in 
some instances more marked above, and in other instances below the 
spinous ridge. Of twelve examinations relative to that point, in pre- 
cisely the same number of instances, viz., in six, the resonance was 
greater in the upper as in the lower scapular space. The intensity 
is almost uniformly greater on the right side. This was true in 
twenty-two of twenty-three observations. The disparity between the 
two sides in different persons varies, in some being slight, in others 
strongly marked. The intensity of the resonance on both sides, also, 
here as in front differs considerably in different individuals. 

A thrill accompanies the resonance in some instances, but less 
frequently than in the infra-clavicular region. Pectoriloquy, perfect or 
imperfect, with words spoken aloud or whispered, was not present in 
any instance ; but with whispered words a souffle was occasionally 
observed, oftener on the right side. 

Infra-scapular region. — In a large majority of cases the vocal 
resonance in this part of the chest is greater than over the scapula : 
it was so noted in fifteen of nineteen examinations, in the remaining 
four instances the resonance being greater over the scapula. The 
resonance in some persons is quite as intense in the infra-scapular as 
in the infra-clavicular region. Here not less than elsewhere, the in- 
tensity varies in different individuals. In much the larger proportion 
of instances, also, there is greater resonance on the right than on 
the left side. This was observed in seventeen of twenty examinations, 
no disparity being apparent in the remaining three. A thrill some- 

1 Recherches sur la Phthisic, 1843. p. 533. 



AUSCULTATION IN HEALTH. 173 

times accompanies the resonance, and occasionally a slight souffle 
when words are whispered. 

Mammary and infra-mammary regions. — The resonance in these 
regions is uniformly less than at the summit of the chest in front : of 
fourteen examinations it is so noted in all. It is also habitually 
greater on the right than on the left side. This is noted in fourteen 
of sixteen examinations, there being no disparity in two instances. 
A thrill accompanies the resonance in some persons. A souffle with 
whispered words is not noted in any instance. The statement by 
some writers that the intensity of vocal resonance diminishes regularly 
from the summit of the chest downward is not applicable to all persons. 
It is sometimes greater over the lower than over the middle third of 
the chest, but these instances are exceptions to the general rule. 
The difference in intensity between the resonance over the upper 
third, and the two inferior thirds of the same side, is in some in- 
stances much more marked on one side than the other, owing not 
only to the disparity existing between the inferior thirds, but to the 
fact that a disparity exists at the summit. 

Axillary and infra-axillary regions. — In the axillary regions the 
resonance is usually greater in intensity than over the middle and 
lower thirds of the chest in front ; and in some instances it is quite 
equal to that of the infra-clavicular region. The intensity is less in 
the infra-axillary than in the axillary region. In some instances the 
difference is slight, in others considerable. A thrill attends the re- 
sonance in some persons in both regions, but oftener in the axillary. 
In both the resonance is habitually greater on the right side : of nine 
comparisons, in eight this disparity was obvious, the resonance 
seeming to be equal in the single exceptional instance. 

In view of the importance, with reference to the diagnosis of dis- 
ease, of the differences existing more or less frequently between corre- 
sponding regions on the two sides of the chest, the following con- 
densed abstract of the foregoing facts pertaining to the respiration 
and voice is appended : 

BRIEF SUMMARY OF FACTS 

Relating to disparity hetween corresponding regions on the two sides of the 
chest, in healthy individuals, as respects the phenomena incident to respi- 
ration and the voice. 

1. Infra-clavicular regions. — More or less of the characters of 



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AUSCULTATION IN DISEASE. 175 



Auscultation in Disease. 

Having studied the phenomena which auscultation of the healthy 
chest discloses, we are prepared to investigate those incident to dis- 
ease. In prosecuting the latter investigation, the general objects are 
as follows : 1. To determine what are morbid sounds and in what 
particulars they differ from those incident to health. 2. To ascertain 
the connection between individual morbid sounds and the physical 
conditions of which, in consequence of this connection, they are the 
signs : 3. To explain, as far as practicable, the manner in which 
morbid physical conditions give rise to the phenomena embraced 
under the head of Auscultation in Disease. Of these three objects 
I shall consider at length, in the remainder of this chapter, the first 
and second, devoting to the third relatively but little attention. As 
already remarked, knowledge of physical signs, their significance and 
value in diagnosis, is not dependent on our ability always to furnish 
a complete exposition of the mechanism of their production. Persons 
may differ in opinion as to the rationale of certain signs, and yet be 
entirely agreed respecting their special meaning and importance, the 
latter being based on the uniform relation found by observation to 
exist between the signs present during life, and the pathological 
changes ascertained after death. It is certainly very desirable to 
explain satisfactorily that connection subsisting between physical 
signs and physical conditions, by virtue of which the former repre- 
sent the latter ; but with our present knowledge, this branch of the 
subject of physical exploration contains many points not fully settled. 
In a work intended to be practical, it would be out of place to dis- 
cuss opinions and theories relating to questions which are as yet 
open for speculation ; and I shall therefore content myself with 
giving, as concisely as possible, different views, without attempting a 
full consideration of their respective merits. 

In treating of auscultation in disease, as in health, the phenomena 
incident to respiration, the voice, and the act of coughing, are to be 
considered under separate heads. 

PHENOMENA INCIDENT TO RESPIRATION. 

The morbid phenomena incident to respiration admit of a natural 
division, which it is convenient to observe, into. First, the normal re- 
spiratory sounds more or less, and variously, modified ; Second, 



176 PHYSICAL EXPLOBAIIO^T OF THE CHEST. 



sonnds. Laving no existenee in tt- L _ - ^ - 
Of the ^ImmBmsaa, emfairieed in the frsi of these two ; -e 

jiMpo!ii<mai«rqp««8QitedbTtTpe5 exisiiiLgiii he:^' -.„ -_tS« 

liiestadfiLt idio has Madied faitlifiillT normal r r - ^_ _, : : : , ~ ^:-_L_i is 
aiieadj f^™ilisT . !l3iey axe to be foimd in different parts of the respira- 
tBBj apparatus idiea sitirelT free £roia disease, and they Ir n j^s 
<^ atoflosal condilioiis Lj a dbaiige of location. The _ _TLa 
eiabrafied i^ :le second eSass bare no coimTerpans :_ _ Le 
BOi^ids ificideiit to normal req)iration, and pertain exdnsiTeiT :: the 
dbsm^es pnodiieed "^'^ diseas-e. We -will consider tliese r^:- 'i~-:-L? 
s^anttdj. 

1. MoBirizi. PtEEPHLAiroET SoT3ijS. — Limiring -'_- ---:.-::, -- -"_r 
vesicnlar mnrmTir, exchisiTe of the traclieal and Ir _ : . 
the changes vMcli it imdergoes in connection idiL ClIZ :„ :. :_ : 
disease, on analj^is, are resolraUe into Taiions t::: - : 

Its intensitj may "be increased, or diminislied- or :: _: - 
Its quality may be altered, tlie Tesicn' 

paniaHy or completely, to tubularity of - __^. ^_- u. - 
raised, and perhaps in some instances levered. The insp n : : ^ ~ _ 1 
expiratory sotmds may l>e modified separately, or conjointly. Xhe 
inspiratory soxmd may be shortened in :.~^'"'r. and the ei^iratoiy 
prolonged. Tiieir rhytbmieal sueces^ioz _ iigturbed, etc- It 

is, hoveTer, tmnecessary to treat : I modifieaiifMis 

separately- They do not, ; - . l^ oonneeiion 

"witli disease, singly, but se^T. :. mbinalion. 

A jndidous classification of the different l: i: - is severally, 
comprising more or less of tbe foregoinr ' . .z/ . - :.- zo 

a clear apprehension of the subject. An 1 : ^ - : - : ^ ^ - - _ -^ 

the following arrangement suffices.^ 

1- Modifications of the intensity of the Tesicular mnrmur, consist- 
ing of a, increased intensity : L diminished intensitj ; e, suppressed 
respiration. 

2. Modifications of the quality of the respiratory sounds, associated 
generally vith aberrations in pitch, duration, and rhvthm. This 
drdsion vill consist of a. bronchial respiration ; J, broncho-Tesiciilar, 
commonly called rude respiration ; e. caTemous re^iradon. 

3. Modifications of rhythm, consisting of a, shortened inspiratim ; 
ft, prolonged expiration : c. interrupted in^iration or expiration. 



I 



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diaer from liiose -sridcii They adept. 



AUSCULTATION IN DISEASE. 177 

I shall consider all the physical signs derived %■ auscultation which 
consist of modified respiratory sounds, as embraced under the forego- 
ing divisions and subdivisions ; and I shall proceed to describe them 
under distinct heads in conformity with this arrangement. 

1. Increased Intensity of the Vesicular 3Iurmur — Exaggerated 
Respiration. — The respiration is simply increased in intensity, or 
exaggerated, whenever the loudness of the murmur is augmented, the 
normal characters, in other respects, remaining unchanged. The 
sound may be more intense than natural, with, at the same time, 
alteration in quality, pitch, and rhythm. The modifications will then 
fall under other divisions. Merely exaggerated respiration preserves 
the normal characters as regards vesicular quality, pitch, and rhythm. 

It has been seen that the intensity of the normal vesicular murmur 
differs greatly in different persons. How then are we to decide 
whether a certain loudness be normal or abnormal ? If this loudness 
be found over the whole chest, the presumption is that it is natural 
to the individual, and it is not to be regarded as a sign of disease. 
But if, on the other hand, it exist on one side of the chest only, it 
may be presumed to be a result of disease. 

An exaggerated vesicular murmur does not proceed from the por- 
tion of lung affected, but from the healthy lung situated either near 
or remote from the seat of disease. Whenever the lung on one side, 
or a considerable portion of it, is rendered by disease incompetent to 
fulfil its part in the respiratory function, the lung on the other side 
takes on an increased action to supply its place. Hence an increased 
intensity of the respiratory murmur, corresponding in degree to this 
augmented activity, the increase of intensity being most marked at 
the superior and anterior portion of the chest. The exaggerated 
respiration under these circumstances is vicarious, or supplementary, 
and has been called by some writers supplementary respiration, 
Laennec applied to it the title of j:>i«?r27e respiration, from its resem- 
blance to the naturally loud respiration incident to early life. Hyper- 
vesicular respiration is another appellation. 

Any disease which compromises to much extent the respiratory 
function of one lung, occasions an increased functional activity of the 
other. The physical sign of this increased activity, viz., an increased 
intensity of the vesicular murmur, thus, is indirect evidence of the ex- 
istence of disease in the opposite side, but it does not afford any 
information as to the particular form of disease which is present. 
The pulmonary affections with which it is oftenest associated, and in 

12 



178 PHYSICAL EXPLOEATION OF THE CHEST. 

the most marked degtee, are pneumonitis and pleuritis. In the former 
of these affections, occurring in the adult, at least an entire lobe is 
rendered, for a time, nearly or quite incompetent to take part in 
h^matosis, in consequence of the cells being filled with inflammatory 
exudation ; in the latter affection, the lung on one side is more or 
less reduced in volume by the compression of effused fluid within the 
pleural sac. Obstruction to the entrance of air into one lung from 
the presence of a foreign body, pressure of an enlarged bronchial 
gland, etc., will also give rise in the other lung to exaggerated respi- 
ration. Considerable deposit of tubercle on one side may produce it ; 
and also solidification from extravasated blood, carcinoma, etc. 
Undue dilatation of the air-cells, or emphysema, limited to one lung, is d 
another affection to be enumerated in the same category. 

It is stated by Fournet^ that exaggerated respiration ensues in 
healthy lung situated in the immediate vicinity of a local affection 
which compromises or abolishes the function within a limited space. 
For example, surrounding a mass of tubercle he thinks the vesicular 
murmur is rendered unduly intense, and, indeed, he asserts that 
an abnormally increased vesicular murmur in the surrounding healthy 
portion of lung is greater in proportion to its proximity to the point 
of local disease. He cites an instance in illustration of this opinion, 
and in which advantage of the fact was taken in arriving at an early 
diagnosis. A patient attacked with all the symptoms of pneumonitis, 
presented no physical signs of disease save exaggerated respiration 
on one side of the chest ; in a short time the exaggerated respiration 
was replaced by the physical signs of pneumonitis. The explana- 
tion offered by Fournet is, that the inflammation attacked first the 
central portion of the lung, giving rise, while centrally situated, to 
exaggerated respiration in the healthy vesicles surrounding the 
affected portion, and afterward extended to the exterior. Whether 
the principle laid down by the author just named be correct or other- 
wise, is not easily determined, nor is it of importance with reference 
to diagnosis, excepting in such an instance as he has cited ; for, assum- 
ing that the vesicular murmur does become more intense in the healthy 
lung surrounding a diseased portion, for example in tuberculous dis- 
ease, the respiratory sound is at the same time more or less modified 
by the diseased portion in other respects, presenting the character of 
a bronchial or broncho-vesicular respiration. In cases of solidifica- 
tion of an entire lobe from pneumonitis, according to Fournet, the 

' Recherches Cliniques, etc. 



AUSCULTATION IN DISEASE. 179 

vesicular murmur proceeding from the other lobe or lobes of the 
aflfected side is exaggerated, and in a more marked degree than that 
proceeding from the healthy side. Without having taken pains to 
analyze a series of observations with respect to this point, I should 
express a different opinion, speaking from the impressions derived 
from my own experience. I am certain that in some cases, at least, 
the vesicular murmur over the healthy lobe or lobes of the aflfected 
side, is notably less intense than on the opposite side, and even below 
the normal intensity. This is found to be true in a case of pneumo- 
nitis under observation at the very moment that I am penning these 
remarks. 

When the vesicular murmur is abnormally exaggerated, the dura- 
tion of the inspiratory sound, as a general rule, is somewhat in- 
creased. This is because the murmur is heard during the entire act 
of inspiration, while, if the intensity be not increased, the sound is 
too feeble to be heard at the beginning of the act when the intensity 
is the least. The expiratory sound is also much oftener heard, and 
is comparatively longer in duration. This is due to the fact that the 
exaggeration aflfecting equally the sounds of inspiration and expira- 
tion, the latter becomes appreciable when, with ordinary normal 
breathing, it is too feeble to be heard ; and for the same reason it 
acquires a longer duration. In pitch, rhythm, and quality, the expi- 
ratory sustains the same relation to the inspiratory sound, as when 
the two are not exaggerated. This is a fact important to be borne 
in mind if we would not be led astray by the greater loudness and 
longer duration of the expiratory sound, — a prominent feature, as will 
be seen hereafter, of the bronchial respiration. In simple exag- 
gerated respiration the expiratory sound is lower in pitch than the 
inspiratory, and is continuous with the sound of inspiration, these 
being the characters belonging to the vesicular murmur when its 
intensity is not increased. In each of these points it differs from the 
bronchial respiration. With due attention to these points of dif- 
ference I cannot conceive that the two need ever be confounded, an 
error which Barth and Roger state is liable to be committed. An 
exaggerated vesicular murmur approaches nearer to a cavernous, than 
to a bronchial respiration ; but the coexisting symptoms and signs, 
in connection with the fact that it is not circumscribed within a 
limited space, as is the cavernous respiration, sufl&ce for discrimina- 
tion. 

An abnormal intensity of the vesicular murmur is attributable. 



180 PHYSICAL EXPLORATION OF THE CHEST. 

as has been stated, to an increased activity of respiration, by way 
of compensation for suspended function in a portion of the pul- 
monary organs. This increased activity can only proceed from 
an expansion of the chest beyond the limits of ordinary normal 
breathing, and with greater force than is employed in health, in con- 
sequence of which a larger quantity of air is drawn into the bronchial 
tubes, giving rise to a more powerful expansion of the lung ; and 
under these circumstances, a larger number of cells are dilated than 
in ordinary breathing. Hence the exaggeration of the respiratory 
sound, the intensity of which depends on the conditions just men- 
tioned. And the fact that in pleuritis, pneumonitis, and tuberculosis, 
the movements of the affected side are more or less restrained, while 
those of the opposite side are increased, would lead us to anticipate 
what (in opposition to the opinion of Fournet), I suspect a series 
of observations would show to be true, viz., that in these affections 
the exaggerated respiration is limited to the opposite side of the 
chest. 

As a physical sign of disease exaggerated respiration does not 
possess great importance. Isolated from other signs it would be 
insignificant in diagnosis. Taken in connection with other signs it is 
deserving of attention. 

2. Diminished Intensity of the Vesieidar Murmur. — Feeble or 
Weak Respiration. — The effect of disease is much oftener to diminish, 
than to increase the intensity of the vesicular murmur. Feeble or 
weak respiration is an abnormal modification of very frequent occur- 
rence, and it is a physical sign incident to numerous and varied 
morbid conditions. 

This species of modification, like that just considered, consists of a 
greater or less diminution in loudness of the respiratory sound, the 
distinctive characters of the vesicular murmur, pertaining to quality, 
pitch, and rhythm remaining unaffected. A respiratory sound may 
be lessened, as well as increased in intensity, with at the same time, 
alteration in quality, pitch, and rhythm, in which case, the aber- 
ration would not fall under the present head, but under those 
belonging to other divisions of abnormal sounds. In duration, the 
inspiratory sound is frequently shortened when its intensity is ab- 
normally diminished, the explanation being precisely the converse of 
that of the longer duration when the murmur is exaggerated. An 
expiratory sound may or may not be heard. In one form of disease 
characterized by feeble respiration, it is frequently present and pro- 



AUSCULTATION IN DISEASE. 181 

longed, the diminution of intensity being less marked than in the 
inspiratory sound. Except in this affection (emphysema), an ex- 
piratory sound is rarely heard, and is not prolonged, provided the 
modification consists in a simple weakness of the murmur, exclusive of 
any other change. 

The various morbid conditions which may induce abnormal feeble- 
ness of the vesicular murmur produce this result by four different 
modes singly or combined, viz., 1. By obstructing the passage of air 
in some portion of the air-tubes ; 2. By obstructing or over-distending 
the air-vesicles ; 3. By removing the lungs from the thoracic walls ; 
4. By restraining the movements of the chest. Under these several 
heads I will proceed to mention the more important of the affections 
in which simple diminution in intensity of the vesicular murmur may 
be expected to occur, premising that alone, this sign, as well as 
exaggerated respiration, fails to furnish information respecting the 
nature of the affection of which it is an effect. To determine the 
latter point, it must be taken in connection with other signs and with 
symptoms. In this respect, however, it differs from exaggerated 
respiration, viz., it often indicates directly the seat of disease, 
in other words, the diminished intensity of the murmur corresponds 
in its situation to the locality of the affection upon which it depends. 

a. An obstruction in any portion of the air-tubes lessens the loudness 
of the vesicular murmur by reducing the quantity of air which pene- 
trates the cells. Laryngeal affections, for example, croup, oedema, 
spasm of the glottis, vegetations which contract the calibre of the 
canal in this situation, involve this result. The space within the 
trachea may be reduced, in like manner, by inflammatory deposits, 
or morbid growths. These causes will diminish the murmur equally 
on both sides of the chest. An obstruction, however, may be seated 
in one of the large bronchi, and then the effect upon the respira- 
tory sounds will be limited to the corresponding side. This obtains 
when a foreign body is lodged in one of the bronchial divisions, 
which occurs oftener on the right side. A foreign body within 
the air-passages sometimes changes its place, being at times thrown 
upward into the trachea, and occasionally transferred, alternately, 
from one of the bronchi to the other. The abnormal feebleness of 
the vesicular murmur, under these circumstances, will be variable in 
degree, at different times, and present itself now on one side, and 
now on the other side of the chest. This intermittence and altera- 
tion afford evidence that the physical sign is due to a movable 



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AUSCULTATION IN DISEASE. 183 

feeble vesicular murmur, therefore, characterizes the affection called 
emphysema. In this affection the expiratory sound is frequently 
prolonged, in consequence of the slowness with which the lungs 
collapse, and of the obstruction to the passage of air in the bronchial 
tubes which often coexists, arising from bronchitis and spasm. Pro- 
longed expiration will be considered under a distinct head. I may 
remark here that, occurring under the circumstances just mentioned, it 
is to be distinguished from its occurrence under circumstances in 
which its pathological significance is quite different, by the attendant 
circumstances, and by its preserving the normal relation, as respects 
pitch, to the inspiratory sound. 

The physical signs derived by percussion in the two forms of 
obstruction within the vesicles just noticed, viz., from morbid deposit 
and over-inflation, are directly opposite in character. In the former 
instance, whether the deposit be tubercle, coagulable lymph, etc., the 
percussion-sound is more or less dull. In the latter, the resonance is 
abnormally clear. This alone would sufiice for the discrimination 
between these two kinds of vesicular obstruction. 

c. If the lungs are removed at a certain distance from the thoracic 
walls, the intensity of the murmur is diminished. Under these cir- 
cumstances, the sound conveys to the mind the idea of distance ; it 
does not seem to be produced in close proximity to the ear, but to 
come from a source somewhat remote. The appreciation of distance, 
which undoubtedly belongs to the perception of impressions received 
through the sense of hearing, in other instances than this, will be 
found to furnish an attribute to physical signs. The lungs must not 
be removed beyond a certain limit, else the respiratory murmur will 
fail to be transmitted. The feeble respiration produced in this way 
occurs when there exists a small quantity of liquid effusion, of air, 
or gas, within the pleural sac ; and when the pleural surfaces are 
covered with a thick layer of coagulable lymph. When it is due to 
the presence of liquid, the effect on the respiratory sound will be 
manifested at the lower part of the chest, provided the position of 
the patient be upright, and its situation may be found to vary with 
the different positions which the patient assumes.^ 

d. The intensity of the vesicular murmur, other things being equal, 
depends on the extent and force of the respiratory movements. Any 
morbid condition, therefore, which limits these movements will render 

' That a thin stratum of liquid may be equally diffused over the lung, as contended 
by Woillez, may fairly be doubted. 



184 PHYSICAL EZPLOEATIO^' OF THE CHEST. 

the respiratory sound abnormally feeble. For example, in a case of 
incomplete general paralysis, which recently came under my observa- 
tion, the respiratory mnscles were in a measure iQYolyed. The respi- 
ratory movements were wanting m strength, and the vesicular murmur 
was correspondingly feeble on both sides. In cases of hemiplegia, 
this effect obtains on the paralyzed side. In pleurisy, before effusion 
has taken place, and in pleurodynia, the pain occasioned by the expan- 
sion of the chest on the affected side leads the patient instinctively 
to restrain the movements on that side. Hence, abnormal feebleness 
of the vesicular murmur belongs equally to both these affections, 
irrespective of the additional cause already mentioned, incident to 
the first at a later period. The movements of the chest on one side 
may be restrained mechanically, in consequence of permanent contrac- 
tion as the sequel of chronic pleurisy, of morbid pleuritic adhesions, 
of injury to the thoracic walls, and deformity. 

Whenever by any of the modes just named the vesicular murmur 
is rendered abnormally feebler on one side of the chest, the respiratory 
sound on the other side is likely to become exaggerated, and the con- 
trast between the two sides is thereby enhanced. 

It is needless to state that in order to judge of abnormal feebleness of 
the Tesicular murmur, as of most of the physical signs, there is no 
ideal standard to which reference is to be made, but it is determined 
by comparison of corresponding regions of two sides of the chest. In 
drawing inferences from the results of this comparison, it is sometimes 
highly important to bear in mind the fact, that in a certain propordon 
of individuals in good health and with chests well formed, a natural dis- 
parity exists as regards the intensity of the vesicular murmur. This 
fact has appeared in the portion of this chapter devoted to the results 
of auscultation in health. A natural disparity may mislead the aus- 
cultator, the greater relative feebleness on the one hand, or on the 
other hand, a normal exaggeration, being attributed incorrectly to 
disease existing on one or the other side. This liability to error is not 
to be lost sight of, especially in the diagnosis of tuberculous disease, a 
disease in which in certain cases few and slight deviations from equa- 
lity of the two sides at the summit of the chest, are jnstly regarded 
as highly significant. The results of examinations of the healthy 
chest not only enforce the caution just given, but lead to another 
very important consideration. In much the larger proportion of in- 
stances of relative feebleness of the vesicular murmur on one side 
compatible with health, it is observed on the right side. It foUows from 



AUSCULTATION IN DISEASE. 185 

this fact that comparative feebleness on the right side is mucli less 
likely to be the result of disease than when it is found to exist on 
the left side. A relatively feeble murmur on the leftside in the great 
majority of instances denotes disease ; but existing on the right side, 
in a considerable proportion of cases it is due to a natural disparity. 

Diminished intensity of the vesicular murmur, when it is evidently 
attributable to a morbid condition, as already remarked, alone, gives 
little or no information respecting the particular condition upon 
which it depends. Isolated from other signs, therefore, and from 
symptoms, its diagnostic value would be small, but associated with the 
information derived from other sources it becomes a valuable sign. 

3. Suppressed respiration. — The respiration is said to be suppressed 
when no sound whatever is appreciable by auscultation : the re- 
spiratory acts take place without giving rise to any audible phenomena. 
This effect may be produced by each of the four modes which have 
been seen to occasion abnormal feebleness of the respiratory murmur : 
their operation being pushed to a certain extent, the sound is abolished. 
Suppression is therefore liable to occur in connection with any of the 
various morbid conditions which induce feebleness of respiration. This 
being the case, it is only necessary under this head to repeat an enu- 
meration of the affections which were mentioned in connection with 
the modification last considered. 

Obstruction of the larynx from inflammatory exudation, oedema- 
tous infiltration, vegetations, spasm, or the presence of a foreign body, 
may extinguish all sound over the entire chest. A foreign substance 
lodged in one of the bronchi may produce this effect on the corre- 
sponding side, giving rise to exaggerated respiration on the other side. 
Absence of all sound obtains in some cases of bronchitis, from the 
swelling of the membrane. Its temporary absence over a portion of 
the chest, owing to an accumulation of mucus in some of the bronchial 
tubes, is occasionally observed in that affection ; and under these cir- 
cumstances it is sometimes abruptly restored in consequence of the 
removal of the obstruction by an act of coughing. Pressure of an 
enlarged bronchial gland, or other tumor, on a bronchial tube, may be 
sufficient to produce complete absence of sound. 

In some cases of pneumonitis, tuberculosis, pulmonary apoplexy, 
oedema, etc., the respiration is suppressed. The vesicular murmur is 
generally abolished in connection with these affections over the solidi- 
fied portion of the lung, but, as will be seen presently, the murmur 
frequently is replaced by a respiratory sound modified in quality, etc., 
viz,, the bronchial respiration. In some cases of emphysema no respi- 



186 PHYSICAL EXPLORATION OF THE CHEST. 

ratory sound is appreciable. In this affection the inspiratory sound 
may be suppressed, and the expiratory, more or less prolonged, 
remain. The expiratory sound is also alone appreciable under other 
circumstances, which "Rill claim notice under other heads. 

Again, when the lungs are removed beyond a very limited space 
from the thoracic walls, either by the presence of liquid effusion in 
plem-isy and hydrothorax ; of air or gas in pneumothorax, or of both 
conjoined in pneumo-hydrothorax, the sound of respiration is gene- 
rally extinct. 

Finally, from contraction, deformity, injmy, or paralysis, the move- 
ments of the chest may be insufficient to produce a respiratory sound. 

Suppressed respiration is a barren sign as regards special signifi- 
cance, disassociated from other physical, and from vital phenomena. 
Thus, when absence of sound exists on one side of the chest, it may 
be incident to pneumonia, emphysema, pleurisy, or pneumothorax. 
Of course no inference can be drawn from the isolated fact that there 
is no respii'atory sound, as to which of these several affections is 
present. But associated with the evidence afforded by percussion, 
and other methods of physical exploration, in connection with symp- 
toms, the diagnosis is usually not attended with much difficulty. In 
point of frequency, absence of respiratory sound oftener proceeds 
from liquid effusion within the chest than from any other morbid 
condition. 

The respiration will be feeble or suppressed in certain cases of dis- 
ease according to the acuteness of hearing of the auscultator. A 
person with a delicate perception of sound will sometimes appreciate 
a weak respiratory murmur, when another person whose auditory 
perceptions are more obtuse will fail to discover any sound. The 
mode of exploration will also affect the result. A murmur may be 
appreciable by immediate, and not by mediate auscultation ; and with 
Cammann's stethoscope, the respiratory sound is distinct in some 
instances in which, with the ordinary cylinder, and the naked ear, it 
cannot be perceived. 

The foregoing modifications relate mainly to deviations from 
healthy respiration as respects intensity, including the abolition of 
sound. Those to be next considered, involve, either with or without 
these deviations, a change in the quality of sound, associated gene- 
rally, also, with abnormal changes in pitch, duration, and rhythm. 
This class of modifications embraces signs of great importance in 
physical diagnosis. 



AUSCULTATION IN DISEASE. 187 

4. Bronchial respiration. — Under the head of bronchial respira- 
tion, I embrace all sounds which, in addition to this title, are called 
blowing and tubular, exclusive of cavernous respiration, to which the 
former of the two terms last mentioned will equally apply. Laennec 
described a blowing respiration distinct from the bronchial and 
cavernous. In this he is followed by Walshe and others. For all 
practical purposes it suffices, and, indeed, as it seems to me, with 
sufficient intrinsic propriety, to consider both as essentially the same 
species of modification, presenting in several particulars, as will be 
presently seen, variations in different cases. This view of the sub- 
ject is sanctioned by high authority.^ 

The appellation bronchial respiration imports that the sound corre- 
sponds to that heard over the sites of the bronchi in the healthy 
chest. The term, however, has a more comprehensive signification. 
It includes sounds analogous to those produced within the larynx and 
trachea. A morbid bronchial respiration maj be defined to be a re- 
spiratory sound resembling or identical with the normal bronchial or 
the laryngo-tracheal respiration, supplanting the vesicular murmur 
in a part of the chest to which this murmur belongs in a healthy 
condition — in other words, elsewhere than at the upper portion 
of the sternum, and on either side, near the sterno-clavicular junc- 
tion, and at the upper portion of the interscapular space, these 
being the situations where the normal bronchial respiration is to 
be sought for. With this definition, the student familiar with the 
characters which distinguish the tracheal and bronchial sounds from 
the vesicular murmur, which have been considered fully under the 
head of Auscultation in Health, will have no difficulty in understand- 
ing and in practically recognizing the bronchial respiration incident 
to disease. In describing the essential traits pertaining to morbid 
bronchial respiration, it is only necessary to reproduce the descrip- 
tion already given of the tracheal and bronchial sounds contrasted 
with the vesicular murmur. The distinctive characters are as fol- 
lows : An inspiratory sound, tubular or blowing, in place of the 
peculiar character to which reference in the foregoing pages has 
frequently been made under the name of the vesicular quality; 
shorter in duration, commencing with the beginning of the inspiratory 
act, and ending before the act is completed ; the pitch of the sound 
higher. An expiratory sound, prolonged, frequently nearly or quite 
as long, and sometimes even longer than the inspiratory, succeeding 

*■ Earth and Roger. 



188 PHYSICAL EXPLORATION OF THE CHEST. 

the inspiratory sound after an interval, owing to the fact just stated, 
that the inspu-atory sound ends before the completion of the respira- 
tory act ; the pitch of sound higher than that of the inspiratory, and 
the intensity generally greater. The student is again requested to 
impress on the memory these several points of distinction, with refer- 
ence to the discrimination of bronchial respii-ation, not only from the 
vesicular murmur, but from another modification included in this class, 
called the cavernous respiration. At the risk of incurring the charge 
of a needless repetition, in order that the points distinguishing the 
bronchial, may be again contrasted with the characters belonging to 
the vesicular respii-ation, the latter are reproduced in this connection. 
They are as follows : An inspiratory sound characterized by the 
vesicular quality ; lower in pitch than the tracheal or bronchial in- 
spii'ation. An exj^iratory sound, when present, much shorter in 
duration, less intense and lower in pitch than the sound of inspira- 
tion. 

Contrasted with the vesicular respiration, the bronchial is said to 
be characterized by greater hardness and dryness. These terms, 
although in vogue since the time of Laennec, do not seem to me to 
express properties of sound, of which, in this comparison, the mind 
receives a very distinct idea. The distinctions pertaining to intensity, 
rhythm, quality, and pitch, are much more definite, and are sufficient 
of themselves for the discrimination. I shall therefore dispense with 
the use of the former terms after this allusion to them. They appear 
to me to be rendered superfluous, especially by attention to variations 
in pitch, an aspect under which respiratory sounds have hitherto 
been but little studied. 

The intensity of the bronchial respiration varies gi-eatly, not only 
in different afi"ections to which it is incident, but in difierent cases of 
the same disease. It is not to be distinguished practically by its in- 
tensity so much as by the other characters which belong to it, and 
the latter may be present, and sufficiently marked, when the sound is 
feeble, as well as when it is loud. The intensity, however, in certain 
afi'ections, pneumonitis especially, is often great, being equal to and at 
times exceeding that of the normal tracheal respiration. In some 
instances of intense bronchial respiration, the sound, in addition to a 
strongly marked tubular quality, has a peculiar ringing, like that pro- 
duced by blowing through a tube of metal, and hence called a metallic 
intonation. It is oftener marked in the expii'atory than in the inspi- 
ratory sound. The normal tracheal respiration occasionally presents 



AUSCULTATION IN DISEASE. 189 

this character in forced breathing. This is an incidental feature of 
the bronchial respiration occurring in certain cases of pneumonitis, 
and not possessing special diagnostic significance. 

In others of the ordinary characters than intensity, the bronchial 
respiration varies. The pitch is not the same in all cases, but this 
difference obtains in different persons as respects the tracheal and the 
normal bronchial sounds. Both the inspiratory and expiratory 
sounds vary in duration, as well as in their relative intensity. Either 
may be present without the other. In some instances the sound 
appears to be produced in close proximity to the ear ; and some- 
times, indeed, the air appears to enter and again emerge from the 
meatus. This was the ground of Laennec's division into bronchial 
and blowing respiration, the latter term being applied when the auscul- 
tator experiences a sensation as if the breath of the patient actually 
traversed the stethoscope. It suffices, however, to consider this as 
simply an incidental feature of the bronchial and possibly of the 
cavernous respiration. In some instances in which this is strongly 
marked, the illusion is almost complete, and, quoting the language of 
Laennec, " it is only from the absence of the feeling of titillation and 
of warmth or coldness which a blast of air so impelled must neces- 
sarily occasion, that we are held to doubt its reality." 

In other cases the sound gives the impression of emanating from a 
source more or less distant from the walls of the chest. It is impor- 
tant to be borne in mind that not only is the bronchial respiration 
incident to different cases of disease, thus variously modified, but that 
all the characters which serve to distinguish it from the vesicular 
respiration are by no means uniformly present. The existence of an 
inspiratory without an expiratory sound, and vice versa, divests it of 
several of the distinctive traits which are associated when a sound 
coexists with both acts of respiration. In such instances we are to 
determine that the respiratory sound is bronchial by the characters 
which remain. The bronchial respiration, like the tracheal, differs 
in intensity, and in other respects, with different successive respira- 
tions, always, however, preserving certain characteristics. Skoda 
contends that it is an intermittent sign, frequently ceasing for a 
series of inspirations, and then reappearing. This does not, however, 
accord with the experience of others, the latter, so far as my observa- 
tions go, being correct as the general rule. Its occasional cessation 
and reappearance after coughing and expectoration, is a fact which I 
have distinctly observed. 



190 PHYSICAL EXPLORATION OF THE CHEST. 

With what physical condition of the lungs is the bronchial respira- 
tion associated ? This question may be explicitly answered. It is inci- 
dent to abnormal density of the pulmonary structure. Whenever the 
bronchial respiration is present it denotes increased density of lung.^ 
The converse of this, however, is not true, viz., that whenever the 
density of lung is increased it gives rise to bronchial respiration. The 
sign always denotes the morbid physical condition just stated, but as 
will be seen presently, the physical condition may exist without giving 
rise to the sign. Increased density of lung is incident to diseases 
which induce condensation by pressure. This effect follows the accumu- 
lation of liquid within the pleural sac, within the pericardium, and 
the development of tumors encroaching on the thoracic space. Much 
oftener, however, it proceeds from a morbid deposit within the pul- 
monary structure. Bronchial respiration, therefore, may be a sign, 
on the one hand, of pleurisy, or hydrothorax, or hydro-pericardium, 
of aneurismal and other tumors ; and, on the other hand, of pneumo- 
nitis, tuberculosis, oedema, carcinoma, and pulmonary apoplexy.' Of 
the several affections last-mentioned, it is more constantly present in 
the two first, viz., pneumonitis and tuberculosis. On this account, and 
owing to the frequency of these affections, the sign is especially 
important with reference to their diagnosis. Before directing further 
attention to it in connection with these affections respectively, we will 
inquire how does the increased density of lung incident to different 
forms of disease give rise to a bronchial respiration ? To this inquiry 
I shall devote brief consideration. 

The explanation of bronchial respiration offered by Laennec, and 
up to the present time generally accepted, is that the sound is in fact 
the normal bronchial respu'ation, which, owing to conditions of disease 
is transmitted to the ear, disconnected from the vesicular respiration. 
The bronchial respiration appears in connection with physical condi- 
tions which involve suppression of the vesicular murmur. In health,. 
the latter, as it were, stifles any sounds emanating or propagated 
from the bronchial tubes. Moreover, the lung, when its density is 
increased, has been supposed to become a much better conductor of 
sound than air-vesicles filled with air. These two circumstances, 
viz., abolition of the vesicular murmur, and the transformation of 
the pulmonary substance into a better conductor of sound, in the 
opinion of Laennec, are sufficient to account for the bronchial respi- 

* As an apparent exception to this statement, dilatation of the bronchise might be 
cited. Dilatation is, however, as will be seen hereafter, always associated with in- 
creased density of lung. 



AUSCULTATION IN DISEASE. 191 

ration, the source of the sound, according to him, being the large and 
small bronchial tubes. The sufficiency of this explanation has been 
called in question, in consequence of the bronchial respiration incident 
to disease being sometimes more intense than even the tracheal sounds ; 
and, differing from the tracheal and normal bronchial respirations, in 
some cases, in quality and pitch. The fact that solidification of 
lung, when the bronchial tubes are free from obstruction, is not 
invariably associated with the bronchial respiration, but in some 
instances gives rise to suppression of all sound, is thought to militate 
against the hypothesis of Laennec. Again, when the lung is solidi- 
fied, as in cases of pneumonitis, it is doubted by some whether, owing 
to its inability to collapse and expand with the two respiratory acts, a 
current of air circulates in the pulmonary bronchial tubes with suffi- 
cient force to give rise to sound. Finally, according to Skoda, 
increased density of the lung does not render it a better conductor of 
sound. The latter statement is based on comparative experiments, 
made with the pulmonary organs removed from the body in a healthy 
condition, and when solidified by disease. Other observers, how- 
ever, from similar experiments, do not arrive at the same conclusion. 
Walshe states, as the results of experiments made by himself, that 
sound may be conducted with great intensity by solidified lung, but 
not invariably ; and that as regards the conducting power, when the 
physical conditions to all appearances are the same, diff'erences are 
found to exist which it is not easy to explain. That a current of 
air is not received into the pulmonary bronchial tubes by the act of 
inspiration, and expelled by expiration with sufficient force to gene- 
rate a tubular sound, is assumed rather than established. The move- 
ments of the chest on the afiected side, in cases of pneumonitis, with 
solidification of one or more lobes, are not much, if at all, diminished 
either in power or extent ; and it seems altogether probable that, not- 
withstanding the comparative incompressibility of the lung, the bron- 
chial tubes remaining unobstructed undergo alternate contraction 
and dilatation.^ The opinion of Andral, that the obstruction to the 
entrance of air into the air-cells by arresting suddenly the current, 
and increasing the pressure of the air upon the bronchial tubes, tends 
to develope an exaggerated sound therein, although repudiated by 

' That air circulating in the bronchial tubes does play a part in the mechanism, would 
seem to be a rational inference from the fact, that the removal of mucus by expectora- 
tion is sometimes observed to be followed at once by the reappearance of the bronchial 
respiration, which, immediately before had been found to be absent. 



i 



192 PHYSICAL EXPLOEATIOX OF THE CHEST. 

high authority, is not disproved, and seems rational.^ With regard 
to the greater intensity of the bronchial than the tracheal respira- 
tion, in some cases, and yariations in pitch, it is certain that differences 
as respects these characters, do exist in a certain proportion of cases. 
A morbid bronchial respiration is sometimes not only more intense i" 
.than the sound emanating from the trachea of the same person and 
at the same time, but notably higher in pitch. It may also present 
a metallic quality, when the tracheal sound of the same person at the 
same time is devoid of this quality. IN'evertheless, as respects the 
distinctive characters which the tracheal and normal bronchial respi- 
ration present in contrast with the vesicular murmur, they belong 
equally to the bronchial respiration incident to disease. The latter, 
when strongly marked, as, for example, frequently in cases of pneumo- 
nitis, is identical with the sounds heard over the trachea as regards tubu- i 
larity, duration of the inspiratory and expiratory sounds, the rhyth* .^ I 
mical succession of the latter, and their relative intensity and pitch, 
these constituting, as has been seen, the traits by which these sounds 
are distinguished from the vesicular murmur. This being the case, in 
the production of the bronchial respiration incident to disease, the tra- 
cheal and normal bronchial respiration, it is reasonable to infer, must 
either be reproduced'within the bronchial tubes, or conveyed to the 
ear by conduction. Circumstances incidental to their manifestation in 
disease produce in certain cases the variations in quality, pitch, and 
intensity to which reference has been made. According to Skoda, the 
sounds may be reproduced. He attributes the origin of morbid 
bronchial respiration in certain cases, to the principle of consonance. 
The air contained in the pulmonary bronchial tubes, according to this 
view, undergoes vibration consonating with those caused by respira- 
tion within the trachea and large bronchi, in the same way that 
musical notes are repeated upon the strings of a violin or piano-forte 
when the corresponding strings of another instrument in its vicinity 
are struck. This fanciful hypothesis, which appears to be readily re- 
ceived by many, I shall notice somewhat more fully in connection 
with the explanation of vocal signs. The simple fact that the loud- 
ness of the bronchial respiration of disease is often equal to and t 
sometimes exceeds the intensity of the tracheal sounds, suffices to 
disprove it, for a sound reproduced by consonance is always much 
less intense than that which originates it. The variation in pitch 
which is sometimes observed is also fatal to the hypothesis, for a 

* This view is advocated by Dr. Gerhard. Diseases of the Chest, 1846. 



AUSCULTATION IN DISEASE. 193 

i 

:i consonating sound is always in unison with the primitive sound. 
Without denying that sonorous vibrations within the pulmonary 
bronchial tubes may consonate with those which take place in the 
trachea and larger bronchial tubes the disparity in pitch and intensity 
disproves the validity of the explanation under circumstances in 
which, according to Skoda, the principle of consonance is particu- 
larly applicable, viz., when the bronchial respiration incidental to 
disease is intensely developed. 

Regarding, then, the bronchial respiration as consisting of trans- 
mitted sounds, they are produced within the trachea, the bronchi, and 
probably also within the subdivisions of the latter, and are conducted 
by solidified lung to the ear of the auscultator. In what proportion 
they are due, respectively, to the trachea, and the large bronchi 
exterior to the lungs, and to what extent sounds generated within 
the pulmonary bronchial subdivisions may be combined, are points 
not easily determined. It is not difficult to conceive that the sounds 
emanating from the trachea may be conveyed with considerable 
intensity to different parts of the chest, after applying the stetho- 
scope on the back of the neck, and listening to these sounds in that 
situation transmitted through the vertebrae and mass of muscle which 
intervene between the ear and the trachea. The conduction, how- 
ever, of the sounds generated within the trachea, and the bronchi, as 
in the conditions of health, will not suffice to explain the intensifi- 
cation of sound which sometimes characterizes the bronchial respira- 
tion in disease, nor the disparity in pitch Avhich is observed. These 
differences must be owing to some agencies pertaining to the bronchial 
tubes within the lungs, or to the pulmonary structure. Sonorous 
vibrations propagated to the pulmonary bronchial tubes rendered 
firm and unyielding by surrounding solidification, according to Four- 
net, Earth and Roger, and others, are reinforced and strengthened 
by reverberation, and thus acquire an increased intensity. Other phy- 
sical influences are doubtless involved, which are not, as yet, satisfacto- 
rily explained. The fact that frequently, in the aff'ections to which 
bronchial respiration is incident, the respiratory movements are made 
with an abnormal quickness and force, will account for the bronchial 
respiration being more intense than the tracheal with ordinary breath- 
ing in a healthy person, but not, of course, for an intensity greater 
than the tracheal sounds of the patient at the time of the examination. 
It has been seen in connection with the subject of auscultation in 
health, that the intensity of the tracheal sounds is greatly increased 

13 



194 PHYSICAL EXPLORATION OF TEE CHEST. I 

when the respiration is ToliintarilY forced. It is therefore to be borne 
in mind, that the intensity of the tracheal respiration with ordinary 
breathinty in health is not a criterion by -which to judge whether the 
bronchial respiration incident to disease is intensified by some cause 
or causes within the pulmonary organs, but the proper standards of 
comparison are the tracheal sounds of the patient which are incident 
to the same circumstances under which the morbid bronchial respi- 
ration is observed. 

Some of the circumstances acconntrng for differences in different 
cases, as regards the intensity of the bronchial respiration are obrious. 
Other things being equal, the greater the degree of density, the more 
complete is the conduction of sound. If the solidification be continuous f 
from the larger bronchial tubes to the exterior of the lung, the inten- ^ 
sity will be greater than if the continuity be interrupted by healthy i 
structure, not only because air-vesicles containing air conduct sound i 
more imperfectly, but also from the fact that the strength of sonorous 
vibrations is impaired by passing from one medium to another. With 
the same amount of solidification, the greater the proximity to the 
larger tubes, the louder will be the sound ; hence, the bronchial respi- 
ration is more strongly marked when the physical conditions favorable 
to its production are situated near the roots of the lungs, in proximity 
to the trachea and large bronchi, and surrounding the immediate ^ 
subdi^isions of the latter. In so far as the sign may be dependent on 
the passage to and fro of air T\dthin the bronchial tubes distributed ^ 
through the lung, it will of course be affected by obstruction of these I 
tubes from the accumulation of mucus or other morbid products. Inji 
addition to these cii-cumstances, there are others which are not fully || 
understood, and which, in some instances, occasion suppression of all 1 
respiratory sound when the conditions favorable for the bronchial f 
respiration appear to be present. The completeness and intensity, 
on the other hand, with which this sign will be presented, will depend I 
on the concurrence of all the circumstances involved in its development 
and transmission. 

The affection in which the bronchial respiration is most constantly 
present, as well as oftenest intense, and in the union of its general 
distinctive characters most complete, is pneumonitis. As this affection' 
in the adult generally is seated in the inferior lobe, and extends overi 
the entire lobe, a weU-marked bronchial respiration conjoined to* 
dulness on percussion over the lower scapular and infra-scapular' 
regions, in conjunction with the symptoms of intra-thoracic inflamma- 



AUSCULTATION IN DISEASE. 195 

tion, is conclusive evidence of the presence of that disease, advanced 
to the second stage, or the stage of solidification. The transition, on 
the surface of the chest, from the vesicular respiration to the bronchial 
is abrupt, and it is generally easy to determine, with the stethoscope, 
the line of demarcation between the two. This line, marked on the 
chest, will be found to pursue the direction of ^the interlobar fissure. 
If this line has been previously determined by percussion, auscultation, 
in the way just mentioned, will afford confirmation of its correctness. 
A sufficiently large collection of cases of pneumonitis will present 
every shade of intensity of the bronchial respiration, and the difierent 
variations in other characters. In some cases an inspiratory sound 
will alone be heard, and in others the expiratory ; in pitch the sound 
may be more or less acute, and it may or may not possess a metallic 
intonation. In a small proportion of cases it is absent, and there is 
suppressed respiration : while, therefore, the bronchial respiration, in 
connection with the circumstances above mentioned, is positive proof 
of the existence of the second stage of pneumonitis, the abolition 
of all respiratory sound, in connection with the same circumstances, 
is not proof that pneumonitis does not exist. In the form of pneumo- 
nitis peculiar to children, lobular pneumonitis, in which the inflamma- 
tion invades irregularly distributed and isolated lobules of both lungs, 
the bronchial respiration is less marked, and for other reasons, more 
appropriately considered hereafter, this sign is much less available 
in diagnosis. 

Next to pneumonitis in the frequency with which the bronchial 
respiration is associated, is tuberculosis. A mass of tubercle, situated 
at the summit of the chest, in proximity to some of the large subdi- 
visions of the bronchi, may give rise to a well-marked, and sometimes 
an intense bronchial respiration, rarely, however, so intense as may 
attend the consolidation from pneumonitis. Existing at the summit 
of the chest on one side, over a space not extensive, conjoined with 
dulness on percussion, and certain symptoms, such as loss of weight, 
pallor, accelerated pulse, and especially haemoptysis, the diagnosis 
hardly admits of doubt. Often, however, in connection with a tuber- 
culous deposit, the respiratory sound, although distinctly modified, is 
not sufficiently so to constitute a well-marked bronchial respiration, 
and the modification will fall under the head to be next considered. 

In oedema of the lungs the bronchial respiration is occasionally 
present, but not often strongly marked, never presenting the intensity 
and metallic quality observed in some cases of pneumonitis. The 



aanee ie "imEe of Tniimonany apopi^zy and Baranxmia of iie inn^'E. 
ZTitQBf ioTiE? <£ dkcase. TnxEPe ^especialrr -fc two last, aape exrpenter- 
jnanee. ffimui "tiieir diagn<^B JnT0iT«5. an iiie ime iMnd. iiie unaiKii 
and. xmiiK' otiier imnd. iiee afeenee of ^igrg amd ^vm^Uim s. ip ^fdn _ 
jeefeenee toL fee made itsr^sh^. 

Uni^issam^ laKgcting -fee ladolt. b -fFeU^nai^ed inromiiiial TssnrraTi : : 
i _L ^ eertjam Tiropartiaii of bsbbs. Of *~ : 

>^ jiininMi^iT. XL tii€ Tf^rik of -fee it^Hpii- J: 

amfl iZin ^{JhariSe. at Snas. ^Barfe and ^i3wsr state :feai iit «xs^ :i 
-: ' Tra? afeent i: -^n. It k incidsart -tc -fiis ar 

111 !._ r iregnentrr - ^n. ie eo-esktenee in -fesm he'^^ ^ 

jnife jte e u ii liug -to IBr. 'Bteett? 'Q jammiiig in -pkmfijr,]! i 4^ - 
::an xiff -fe^ inng ^hmi - -fe lior: " 

tt:; -. _. pkuml «ac. and i -.. . "to snnii^. , ._ 

cd^t. iite HEessiiEe xif -fee £nid Tumung ine hmg mrfrard. ^exeent i: 
5<flne iiiistaneefr in Tmicn it it prev-eui^ec ttqil ~ 

"fee TrpeBsnre. in iiiis drrecnmi. irr morbic: a:.... „._. . ._ i.. .^^. 

snrfeLes . lEn 5<nne esses . inaws^sr . it iB more or l®s difidsed crFer th-^ 
di«5t. ^ucii ca5«= ai^ met "witn iraicii oft^ner among children iL i 
adnfe l^ii^n it^rd beiov -to ierel of -fc finid it is Tarelr in^ ~r 
anc tbe ^guiil «?enj= to eom^einnn a distance. ~hi -fee ^grearm 
xff 'fflffiSSB. Benainir anrong adulbb. sigyprpession oi Tespiratian over t_ 
]^BSt. ii^lov -fes* lerel ^ -fe?e lianid ^nisian. diaraT' :~ - 

^ftenTJBT. TEik. in iatJt. :k "to Tnk. -fee iostanee? in " _r 

dktant 1iTnii t4i«a1 -T»^jnra.iiiTr g apiireciaJiie. iyerng sxjcepimiB. 

TBie pir?sEcal cflfnditi«ifn? in 2 - 
.!re?T. «o fer SEE Ton^eem^ iiiei! ^L . 

jmreh as. in ite affiectian. iic^md ^ifeian TaicsE -piaee in Iwiii suIbe of 
t_ 'iiiii'i '-waiCTn ri 

i^z „ „^ . L , " __ : e-*UlTalwHl. 

_K iarfl]^ ^ompaiiiiie urife i3e. 

-- ajT'sadv sisreed. f!onnrre5iian of ine pnimonarT _ — i 

::_i: causes -fear pisnmic effusion nsTr^rre Tiae t: _ ^_-. 

ipeiDiraTion ^arth and ^x^er sxateiifict in "fcwn iistancs ir -frae 
< ^-feemin eonneciion-wdtti an arenmnialian nf fciic -irifeiL 

"L^ , -.^iTdial «ac. "toaion-e^stenee of lianid in -to-plenra] caTirr. 
and xS^ TmemnamiE. nr soiidin-saiion d&roni ofesr djaaggf . beins' deter- 
imined. bv ainopsica] esaminaiioiiE, lit :k eY&ni -feat a imnar dere- 
\fm^ T^rifeiL or extending imc -fee "ciiestaiKtv prodttee "to ^exn«- effect. 

' II>iseaees o: i»& OsesL -esc. 



AUSCULTATION IN DISEASE. 197 

Abnormal dilatation of tlie bronchial tubes is to be added to the 
foregoing list of affections giving rise to the bronchial respiration. It 
is difficult to determine how much influence is to be attributed to the 
dilatation, since it is generally associated with more or less induration 
of the pulmonary tissue surrounding the dilated tubes. 

From the relations which have thus been seen to subsist between 
bronchial respiration and different pulmonary affections, pneumonitis 
and tubercle more especially, it is sufficiently apparent that it is a 
highly important physical sign, holding very frequently a prominent 
place among the phenomena involved in diagnosis. Practical ac- 
quaintance with its distinctive characters is therefore indispensable to 
the skilful exercise of the art of physical exploration ; and this may 
be readily acquired, since, as has been already stated more than once, 
these characters may be studied as well by means of auscultation in 
health, as in disease. 

5. Broncho-vesicular, or rude respiration, — The abnormal modifica- 
tion commonly called rude respiration, I have ventured to designate 
by a new title, viz., hroncho-vesicular, an appellation expressing both 
the character and source of the sounds, while the term rude, in this ap- 
plication, is not only indefinite, but even its correctness admits of ques- 
tion. A bronchial respiration we have seen to be characterized, first 
and specially, by the absence of the vesicular quality, which is re- 
placed by a tubular or blowing sound ; now, in certain forms of disease, 
the respiratory sound presents the tubular or blowing and the vesi- 
cular qualities, combined in varied proportions; and, at the same 
time, other of the characters of the bronchial respiration may be more 
or less associated. This modification I propose to distinguish as the 
broncho-vesicular respiration. 

If the reader will take the trouble to consult different works on 
the subject of phj^sical exploration, he will find a singular want of 
clearness in the manner in which this sign is usually defined ; and it 
is exceedingly difficult for the student to form a correct idea of what 
is intended to be indicated by the term rude respiration. All concur 
in saying that the rude respiration merges insensibly into the bron- 
chial respiration. It is, in fact, neither more or less than an imper- 
fectly developed bronchial respiration, which in the process of certain 
diseases, as will be seen presently, it may both precede and follow. 
Decomposed by analysis it consists of the same elementary charac- 
ters as the bronchial respiration, the chief points of difference being 
that the vesicular quality, although impaired, is not lost. 



19B izt=::ai zz:lo»atic 

In :- .- -_: i:-^ _£:LL;T:Te clis^: 

d^ 

t,'.-—\ '...- ^ : ^ : . . - ; ^ nj 



EST. 




AUSCULTATION IN DISEASE, 199 

present, and sometimes longer. From the fact that the inspiratory 
sound is unfinished, an interval separates the two sounds, as in the 
bronchial respiration. In these several points the reader will not 
fail to notice the identity with the bronchial respiration. This holds 
good still farther. The expiratory sound is higher in pitch, and fre- 
quently more intense than the inspiratory. It was observed by 
Jackson (who first called attention to the importance of the expira- 
tory sound in physical diagnosis), and the fact has been confirmed by 
Fournet and others, that in the development of the rude respiration 
the morbid alteration generally first appears in the expiration. It 
becomes more intense and prolonged. The change in pitch, becom- 
ing higher than that of the inspiratory sound, reversing in this respect 
the condition of health, appears to have escaped observation. This 
change is of considerable importance to be borne in mind ; for, under 
other circumstances, when the expiration is prolonged, indicating 
physical conditions differing from those which give rise to the bron- 
cho-vesicular respiration, the pitch of the expiratory sound does not 
become higher than that of the inspiratory. 

To recapitulate the characters of the broncho-vesicular respiration : 
Inspiration presenting vesicular and tubular qualities mixed ; short- 
ened in duration ; pitch raised ; intensity variable ; sometimes alone 
present. Expiration, oftener present ; frequently existing alone ; 
prolonged ; occurring after an interval ; pitch higher than that of 
inspiration and oftener more intense. 

Keeping in view these distinctive characters, it is not difficult to 
determine clinically the existence or non-existence of the modifica- 
tion under consideration. It should be discriminated readily from 
exaggerated or puerile respiration, after a little experience in physi- 
cal exploration ;^ for, in the latter modification, there is no change in 
quality or pitch of the inspiration, but simply increased intensity ; 
the expiratory is continuous with the inspiratory sound, is less intense, 
and lower in pitch. But if an inspiratory sound be alone present, 
the mixed quality and the elevation of pitch pertaining to the bron- 
cho-vesicular respiration suffice to mark the distinction. It may be 
in some instances a matter of question whether the respiration be 
broncho-vesicular or bronchial ; but this is a point practically of 
little or no consequence, since the one merges insensibly into the other, 

' "La distinction n'est pas tonjours evidente entre la respiration rude et les formes de 
la respiration dite puerile^ etc." Earth and Roger. Op. cit. Other writers make a simi- 
lar statement. 



200 PHYSICAL EXPLORATION OF THE CHEST. 

and when there is room for doubt the bearing on diagnosis in either 
case is the same. The chief liability to error is connected with the 
question whether a broncho-vesicular respiration exists naturally, or 
is due to a morbid condition. To this point I shall presently advert. 

As regards the morbid conditions to which broncho-vesicular respi- 
ration is incident, the respu-atory sounds assume more or less of its 
character in some cases of emphysema. But in the great majority 
of instances it is connected with increased density of the lung, either 
from compression or morbid deposits. The conditions, in other 
words, are identical with those which give rise to the bronchial respi- 
ration ; and the physical principles involved in its mechanism are the 
same, the only difference being that the vesicular murmur is par- 
tially, not completely suppressed. It is therefore met with in the 
same diseases which give rise to the bronchial respiration, viz., 
plemisy and hydrothorax ; compression of the lung by distension of the 
pericardial sac, and tumors ; pneumonitis, tuberculosis, pulmonary 
apoplexy, oedema, and carcinoma. In pleural effusions (pleurisy and 
hydrothorax) it occurs early, when the quantity of liquid is small, 
the lung being subjected to moderate pressure, and again late in the 
process of these affections, when the liquid has been considerably 
reduced in quantity by absorption. In pneumonitis it may also be 
present at different epochs, first indicating a small amount of lym- 
phatic exudation, and, afterward, its removal in a great measure ; in 
the former instance giving place to, and in the latter succeeding 
the bronchial respiration. In general terms, it may be a sign of 
any of the several affections named, provided the condensation or 
solidification of lung be not sufficient to extinguish the vesicular 
murmur, in which case either the bronchial respiration appears, or 
all respiratory sound is suppressed. 

The broncho-vesicular respiration is important, as a physical sign, 
chiefly in the diagnosis of pulmonary tuberculosis in its early stage. 
In this relation it is frequently a sign of great value. When the amount 
of tuberculous deposit is small, so far as the phenomena determina- 
ble by auscultation are concerned, this is the modification most likely 
to be produced ; hence, in conjunction with other signs and symptoms, 
it is often very significant. In fact, the diagnosis may hinge upon 
the question whether a well-marked broncho-vesicular respiration be 
present or not. In this connection it is to be borne in mind (as 
has been stated already), that the several characters which distinguish 
this sign from the healthy vesicular murmur are by no means invari- 



AUSCULTATION IN DISEASE. 201 

ably present. More or less of these characters may be absent, as is 
the case with the bronchial respiration. The distinctive traits are 
nevertheless sufficient for its recognition. For example, an inspira- 
tory sound only may be appreciable. If it be less vesicular, higher 
in pitch, and shorter in duration, together with a greater or less de- 
gree of intensity than the inspiratory sound at the summit of the chest, 
(where the tuberculous deposit first takes place,) at a corresponding 
point on the opposite side, the respiration is broncho-vesicular, as 
clearly almost as if there were added the characters pertaining to the 
expiratory sound. On the other hand, it is perhaps qftener the case 
that the sound of expiration exists alone, or at all events the distinc- 
tive characters may be more strongly marked by the presence of an 
expiratory sound on one side and not on the other, or a prolonged 
expiration on one side, in either case more intense than the sound 
of inspiration and higher in pitch, the reverse being the case on the 
opposite side, if an expiratory sound be appreciable on that side. 
These characters, irrespective of the inspiratory sound, denote a 
broncho-vesicular respiration. 

In the diagnosis of tuberculous disease, before attributing to a 
morbid source the sign under consideration, we are always to inquire 
whether the phenomena may not be incident to a healthy condition ; 
in other words, whether the points of disparity, which may be ob- 
served, do not rank among the variations which are frequently 
found in persons free from all pulmonary disease. This question, in 
some instances, gives rise to more room for difficulty and doubt, than 
a decision as regards the reality of the characters which distinguish 
the broncho-vesicular respiration. It has been seen under the head 
of Auscultation in Health, that the several elements into which the 
bronchial and the broncho-vesicular respiration are resolvable, are to 
be found in a certain proportion of healthy persons at the summit of 
the chest. This fact cannot be lost sight of without the risk of grave 
errors in diagnosis. Errors probably often occur from the w^ant of a 
proper appreciation of this fact. The results of examinations of the 
chest in a series of healthy persons lead to a rule which affords great 
assistance in settling the question just mentioned. If the reader 
will refer to the comparisons of the regions at the summit of the chest 
in health, as respects the phenomena incident to respiration, he will 
see that comparative diminution of vesicular quality and elevation of 
pitch of the inspiratory sound, a more frequent presence of the 
sound of expiration with or without the inspiratory sound, prolonga- 



202 PHYSICAL EXPLORATION OF THE CHEST. 

tion of the latter with greater intensity and elevation of pitch, are 
points of disparity peculiar to the right side. In other words, a 
broncho-vesicular respiration is natural to the summit of the chest, 
in front and behind, in a certain proportion of individuals. This 
being the case, it follows that the question as to this modification of 
the respiratory sound being due to disease, pertains to its presence 
on the right side of the chest. A well-marked broncho-vesicular 
respiration on the right side may not indicate more than a natural 
disparity. To be considered a morbid sign, it must be associated 
with other signs, and with symptoms pointing emphatically to the 
existence of tuberculous disease. As an isolated sim, reliance must 
not be placed upon it in that situation. Non-observance of this 
rule exposes the practitioner to a false diagnosis. On the left side, 
however, the probabilities of the sign being due to a normal disparity 
are very few. In this situation, it is almost of itself positive evi- 
dence of a tuberculous deposit, when other circumstances create a 
suspicion of the existence of phthisis and it is of vastly less importance, 
with reference to the diagnosis, that it be associated with other signs, 
and with symptoms denoting the existence of tuberculous disease. 

6. Cavernous respiration. — The term cavernous imports modifica- 
tions of the respiratory sounds due to the presence of caverns or exca- 
vations within the chest. The formation of cavities of greater or less 
size, belongs to the natural history of tuberculosis of the lungs espe- 
cially ; they result from the production of abscess, as a very rare 
termination of pneumonitis ; also from circumscribed gangrene, and 
from perforation establishing a fistulous communication between the 
bronchial tubes and the pleural sac. The cavernous respiration con- 
sists of the sounds caused by the entrance, with the act of inspira- 
tion, of air into the ca^dties incident to the several affections just 
named, and its expulsion with the act of expiration. Laennec de- 
scribed this sound as resembling that of the bronchial respiration, 
but distinguished by the air seeming to penetrate a larger space than 
that of a bronchial tube. The difference between the cavernous and 
the bronchial respiration, is certainly not very clearly defined in this 
description ; and the two sounds are now considered by many to be 
essentially identical. Skoda advocates this view. The laryngo-tra- 
cheal sounds are frequently referred to by writers on this subject, as 
offering equally a type of the bronchial and cavernous respiration. 
This view does not seem to me to be correct. The cavernous respi- 
ration, I think, is a distinct modification, and, when well-marked, is 



AUSCULTATION IN DISEASE. 203 

discriminated from the bronchial without difficulty, by characters 
which are quite distinctive. These characters relate to intensity, 
quality, pitch, and rapidity of evolution. The intensity is variable. 
It may be feeble, or more or less intense, but never acquiring the 
great intensity which sometimes characterizes bronchial respiration. 
It is rarely the case that it presents the character of the blowing 
respiration of Laennec, viz., the air appearing to enter and emerge 
from the ear of the auscultator. The quality of sound is non-vesi- 
cular, in other words blowing or tubular. It conveys to the ear the 
idea of a hollow space. The difference in this respect, between it 
and the bronchial respiration, may be illustrated by blowing, first, 
into a cavity formed by the two hands, and afterward through a tube 
formed by the fingers and palm of one hand. The pitch is low, com- 
pared with that of the tracheal or the bronchial respiration either of 
health or disease. An expiratory sound may be present, and if so, 
judging from a limited number of observations, the pitch is lower 
than that of inspiration.^ Finally, it is evolved more slowly than 
the bronchial respiration ; in other words, it does not so promptly 
accompany the beginning of the successive respiratory acts. Of the 
descriptive characters just mentioned, those which are specially dis- 
tinctive, as contrasted with the bronchial respiration, relate to pitch 
of sound. The inspiratory sound is lower in pitch than in the bron- 
chial respiration. The sound of expiration is lower than that of in- 
spiration, the reverse obtaining in the bronchial respiration. This 
statement is based on a few observations, in which the phenomena 
were noted during life, the existence of cavities in the situations 
where these characters of the respiration had been studied,^ being 
demonstrated after death. 

In determining, clinically, the existence of the cavernous respira- 
tion, other circumstances than its intrinsic characters are to be taken 
into account. It is heard over a circumscribed area, which corre- 
sponds to the size of the cavity. It is an intermittent sign, being 
absent when the cavity is completely filled with liquid morbid pro- 
ducts. Occurring, in the vast majority of the instances in which it 
exists, in the progress of tuberculosis, it is found at the summit of the 
chest ; the cavities in that affection being formed at or near the apices 
of the lungs. It may be associated with other cavernous signs, to be 
noticed hereafter, viz., pectoriloquy, gurgling, and metallic tinkling. 

' Vide cases in Appendix to Essay by the author, on Variations in Pitch, etc. 
^ Essay on Variations in Pitch, etc. 



204 PHYSICAL EXPLORATION OF THE CHEST. 

Frequently, the symptoms afford strong corroborative evidence of the 
existence of a cavity. 

When a cavity, or cavities, exist in the lungs in connection with 
either of the affections which have been named, the presence of the 
cavernous respiration depends on certain conditions. The cavity 
must be empty, or, if partially filled, the opening or openings with 
which it communicates with the bronchial tubes, must be situated 
above the level of the liquid contents. Intermittency arises from 
the fact that, at different periods of the twenty-four hours, a cavity 
may be completely filled, partially filled, and entirely empty. It is less 
likely to be heard at an early hour of the morning, because liquid con- 
tents usually accumulate during sleep, and are removed by efforts of 
expectoration more or less prolonged, or repeatea, after waking. The 
cavity, of course, must communicate by one or more openings with 
the bronchial tubes. The size of these openings will affect the sign ; 
in the first place, directly, the intensity of the sound, other things 
being equal, being proportionate to the freedom with which the air is 
admitted to the cavity ; and, in the second place, indirectly by favor- 
ing the removal of the liquid contents by expectoration. The open- 
ing or openings, are liable to become temporarily or permanently 
obstructed. Their form and size sometimes are such, that the cur- 
rent of air in passing to and fro, gives rise to adventitious sounds, 
which render the cavernous respiration inappreciable. The bronchial 
tubes leading to the cavity must be unobstructed, and free from loud 
adventitious sounds, which are frequently generated within them. 
The walls of the cavity must not be so rigid and unyielding as not to 
collapse and expand with the alternate acts of inspiration and expira- 
tion ; otherwise, it will not be successively filled with and emptied of 
air. The cavity must be of a certain size, and, other things being 
equal, the cavernous respiration will be marked in proportion to its 
magnitude. The presence of the sign will depend on the situation of 
the cavity. Situated superficially, or near to the exterior of the 
lung, the sound may be appreciable when it would not have reached 
the ear through a layer of pulmonary parenchyma. 

The condition of the lung surrounding, or in the vicinity of, the 
cavity is an important circumstance. Generally there is more or less 
solidification, giving rise to the bronchial respiration. This sometimes 
assists by contrast in determining the presence of a cavernous re- 
spiration, but in other instances it drowns the latter and prevents it 
from being appreciated. In consequence of its dependence on so 



AUSCULTATION IN DISEASE. 205 

many contingencies, it is only in a small proportion of the cases in 
which a cavity or cavities exist, that auscultation succeeds in disco- 
vering a well-marked cavernous respiration ; and frequently in the 
instances in which it is discoverable, it is found only after repeated 
explorations. Fortunately, as a physical sign, it is of less import- 
ance practically than other signs involved in the diagnosis of the 
affections to which the formation of cavities is incident. 

A successful search for a cavity requires considerable care and 
patience. The object is to localize within a circumscribed space a non- 
vesicular respiration, with an inspiratory sound low in pitch, evolved 
somewhat slowly, and an expiratory sound, if present, lower in pitch 
than the inspiratory. Perhaps, to these differential characters should 
be added a certain hollow quality, giving the idea of air entering 
into a cavity, which constitutes the distinctive feature, according to 
most of the writers who recognize a cavernous sound intrinsically 
distinct from the bronchial. The lowness of the pitch of inspiration 
compared with the bronchial respiration is mentioned by Walshe and 
others ; but the relative lowness of the pitch of expiration compared 
with the inspiration, has not to my knowledge, been before pointed 
out. As I have been careful to state, this relation, as regards pitch 
of the inspiratory and expiratory sounds, is based on a few observa- 
tions only, in which, however, the results were positive. If this rela- 
tion be uniform, it must be considered to constitute a highly distinctive 
characteristic of the cavernous, as distinguished from the bronchial 
respiration ; and it is rendered especially important by the fact that 
other signs of a cavity, formerly considered to be distinctive (I refer 
more particularly to the vocal sign, pectoriloquy), have now justly 
ceased to be regarded in that light. The fact of a blowing sound being 
restricted within a circumscribed space, is by no means reliable as suf- 
ficient evidence that the respiration is cavernous. They, who con- 
sider the bronchial and cavernous respirations identical in character, 
are obliged to base the discrimination on that circumstance. But a . 
bronchial respiration, at the summit of the chest, is not unfrequently 
circumscribed within narrow limits ; hence, errors of diagnosis are 
necessarily incident to reliance on this point. Fournet confesses that 
he has fallen into this error. He says : '' Dans ces cas, il est facile 
de prendre le caractere bronchique, pour le caractere caverneuse : je 
m'y suis d'abord trompe quelquefois. . . . . . j'dtais ^tonn^, k 

I'autopsie de ne pas rencontrer la plus petite trace de cavernes." 
Op. cit. p. 101. I have known mistakes arising from this source to 



206 PHYSICAL EXPLORATION OF THE CHEST. 

be committed by experienced auscultators. Taken, however, in con- 
nection with other points, it is of considerable importance ; and in ' 
order better to circumscribe the area whence sounds are received by 
the ear, the stethoscope should be used in preference to immediate - 
auscultation. To determine the non-vesicular quality of the sound 
at a suspected point, a comparison^ may be made of the sound at this 
point with that heard over portions of the chest where the vesicular 
quality is distinctly preserved. To determine that the pitch is lower 
than that of the bronchial respiration, in cases of tuberculosis, the 
sound at a suspected point may frequently be contrasted with that at 
other points at the summit of the chest, where, owing to the presence 
of crude tubercle, the bronchial respiration is well marked. Or, if 
this comparison be wanting, it may be contrasted with the sounds 
heard over the trachea. In some instances, owing to the cavity being 
surrounded by solidified lung, the cavernous respiration will be pre- 
sented in strong contrast to the bronchial respiration, which on all 
sides defines the boundaries of the excavation. 

In one of the" cases in which I succeeded in localizing a cavity, ^ 
the following interesting circumstance was noticed. At the begin- ■ 
ning of the inspiratory act the sound was tubular and high in pitch, / 
but at about the middle of the act the pitch abruptly became low, f 
the blowing quality being still preserved. The inspiration was fol- \ 
lowed by a feeble expiratory sound low in pitch. In this case, a \ 
post-mortem examination revealed a cavity communicating at the | 
point where this peculiarity was observed with a bronchial tube of the f 
size of a goose-quill.^ This instance exemplified a combination of the r 
cavernous and bronchial respiration. mg 

Of the several afi'ections in which a cavernous respiration may be » 
observed, tuberculosis, as already remarked, is the one in which it 

^ There will be a liability, in certain cases, without due attention to the vesicular 
quality, to mistake an exaggerated vesicular respiration for the cavernous. I have cau- 
tioned against this liability in another work (Prize Essay), yet it has been illustrated in 
a case which recently came under observation, in which all the external characters of 
advanced phthisis were presented, and the exploration was limited to the summit of 
the chest. The patient had double pleurisy, with considerable effusion in both pleural 
cavities ; under these circumstances, the superior costal respiratory movements were 
strongly marked, the percussion resonance was tympanitic, and on auscultation, an 
intense inspiratory sound was heard, followed by a prolonged expiration, lower in pitch 
than the sound of inspiration. The respiratory sounds were manifestly not bronchial, 
and were incorrectly supposed to be cavernous. An autopsy disclosed double pleurisy 
with effusion, and a few small disseminated tubercles. 

* Vide Appendix to Essay on Variations in Pitch, etc. 



AUSCULTATION IN DISEASE. 207 

occurs in the vast majority of instances. All the other affections are 
extremely rare. In circumscribed gangrene and abscess moreover, 
the conditions required for the production of the sign, are much more 
unfrequently combined than in the cavernous stage of phthisis. Skoda 
states that in the few instances in which an excavation results from 
pneumonitis, the space is so constantly filled with pus and sanies, that 
it almost never gives rise to distinctive sounds, determinable either by 
percussion or auscultation. In pneumo-hydrothorax the pleural sac, 
which may be more or less circumscribed by morbid adhesions, con- 
stitutes a cavity in which the air may enter with inspiration, and be 
expelled with expiration, through the fistulous communication with 
the bronchial tubes. There is still another mode in which a cavity 
may be formed within the chest, viz., by means of a pouch-like dila- 
tation of a bronchial tube. This is exceedingly unfrequent, but it is 
to be borne in mind as a possible condition giving rise to the sign 
under consideration. In view of the vastly greater ratio of tubercu- 
lous excavations to those incident to all other affections, when the 
fact of the existence of a pulmonary cavity is determined, it might 
be attributed to phthisis, almost by the law of probabilities alone ; 
but the situation of the cavity affords additional evidence. A tuber- 
culous excavation in forty-nine out of fifty cases is situated at or near 
one of the apices of the lung, while, on the other hand, cavities from 
gangrene, abscess, or perforation, are more likely to occur elsewhere. 
As a sign indicating the nature of the disease, in individual cases, 
cavernous respiration is of minor importance. It is discoverable in 
but a small proportion of the cases in which cavities exist. Tuber- 
culous excavations are very frequent. They are found after death in 
most subjects dead with phthisis, and the prevalence of this fatal dis- 
ease in all countries is well known. Yet it is rather rare in cases of 
advanced phthisis, to be able to discover a well-marked cavernous 
respiration, even after repeated, careful explorations. And when 
cavities are formed in the progress of any of the affections named, 
but especially in tuberculosis, occurring at a late period of the disease, 
the diagnosis has already been determined by other signs, together 
with the concomitant symptoms ; hence a cavernous respiration only 
serves to confirm its correctness. Moreover, in each of these affec- 
tions, excepting, perhaps, pouch-like dilatation of the bronchia, the 
signs and symptoms, irrespective of cavernous respiration, are suf- 
ficient to render the diagnosis easy and positive, so that the latter is 
redundant, and except as a matter of scientific interest, hardly com- 
pensates for the pains necessary to discover it. 



PHTSiCAi I z r 1 : ?. ATioar of t^h r-^^s.. 

An abiioiiiialmodiz:i:-::i :: :-e respiratoiy ^ : 
re^iratigm or mt^jaJUm eekt»^ is by some writers 
phj^cal dign. It is incident to a <»¥itj eqna" " : _ i r 
i^sinralion, and both are sometimes combined, Si : . , t 
of their prodaeti<m is n<jt the same. Bnt for 
it suffices to regard the amphoric, as a variety : ^^ 

ration. If a person blow gently into an em: — : ^ 

a decanter, or water-croflt, a sonnd is produce : i _ 

intonation. This sonnd is analogous to tiiat ^- .. : i e 

amphoric respuration ; in other words, wheneve: L j 

soimd presents a ^very or metallic tone it is ^ 

A s :j^ :e perfect imitation is afforded b^ ~ _ 

: 7 :t is inflated to a considerable d^. t t 
L : 1 the ear- This peculiar sound :- .: t r :_ . 1: 

int^isitty. It has been heard even when the ear is removed at a httle 
: e firom the chest. It is generally confined to a dreomscribed 
jnt is sometimes diffused more or less over the chest. It may 
accompany dther respiratoiy act, bnt according to Barth and Boger is 
most apt to attend the act of ios^ralion.^ The mode of its production 
within the chest is probably the same as in the illustration mentioned. 
It is not caused by the firee dTculati<m of air within a cavity, but by 
tiie current of air in the bronchial tubes, acting upon the air contained 
within the cavity. In this reject it differs from ordinary cavernous 
respiration. The spedal conditions which it requires are, a cavity of 
considerable siie, of course free frmn liquid contents, pardaUy or 
entirely, and the walls of the cavity sufficient^ firm not to undergo 
complete contzaetion and dihitation with the alternate acts of inspirar 
ticm and e]qHration. Iq some instances a partial displacement of air 
takes place in ecmseqnence of a certain amount oi eollapee and ex- 
pansion of the walls of the cavity, and then, there may erist a true 
cavernous res]^rali<m with idie amphoric sound superadded. 

The amphoric respration may occur m conneeti<m with any of the 
auctions whidi ^ve rise to carities. It is exceedingly rare, however, 
that an excavation, except it proceed firom tuberculous disease, is <^ 
sufficient dtie an! rr v" " ~'-\ walls sufficiently firm to fiodfil the 
requisile phymes. : j. ". ": i= a very unfirequent phenommon 

in tubearenlons i: 5 t — It :ns are most likely to exist in 

pneumo-hydrotL ; : z r_ " „ i ^ _ :: :le sign is press^it it gene- 



II 



AUSCULTATION IN DISEASE. 209 

; rally denotes that affection. It is stated by Skoda that for the pro- 
: duction of an amphoric sound, a free communication between the 
i bronchial tubes and the pleural sac or a pulmonary excavation is not 
necessary. He thinks that the sonorous vibrations may be communi- 
i cated to the air contained within the cavity, by the column of air in 
j the tubes, through an intervening septum of pulmonary tissue. This 
j opinion, as remarked by Barth and Roger, is supported by the fact 
, that the experiment of producing an analogous sound by blowing into 
I a decanter or water-croft, is successful when the mouth of the vessel 
j is covered by a very thin diaphragm, for example a single layer of 
• letter paper. The sound, under these circumstances, is more feeble, 
and more force in blowing is required. 

Amphoric respiration when present, indicates very positively either 

I pneumo-hydrothorax, or the existence of a large cavity within the lungs. 

Its absence, however, is not evidence that one or the other, or both 

ij morbid conditions do not exist. This remark, which is applica- 

j ble to ordinary cavernous respiration, is still more so to the amphoric 

I variety. Considering its infrequency, and in view of the fact that 

: the diagnosis of the affections, in connection with which it occurs, is 

in no wise dependent upon it, the sign is interesting more as a clinical 

curiosity than for its practical value. 

The three forms of morbid respiration just considered, viz., the 
bronchial, the broncho-vesicular, and the cavernous, constitute the 
subdivisions of the class of auscultatory phenomena embracing ab- 
normal modifications in quality, pitch, etc., of the normal respiratory 
sounds. In place of a summary of the distinctions which have been 
described in the preceding pages, the subjoined tabular view is ap- 
pended, by means of which the reader may review, at a glance, the 
distinctive characters pertaining to the three forms of morbid respira- 
tion just mentioned, and compare them with the characters which 
belong to the healthy vesicular murmur. 

Tabular Vieio of the Distinctive Cliaraders pertaining to the Different Abnormal 
Modifications in Quality, Fitch, etc., of Respiratory Sounds. 

Normal Vesicular Murmur, 

Inspiration. Expiration. 

Vesicular in quality. Low in pitch. Short in duration, averaging about l-5th 

jLonger than expiration as 5 to 1. length of inspiration. Less intense than the 

i inspiration. Often absent. Pitch lower 

I than that of inspiration. Inspiration and 

j expiration continuous. 

i 14 



210 PHYSICAL EXPLORATION OF THE CHEST. 

Bronchial Respiration, 
Inspiration. Expiration. 

Tubular in quality. Pitch raised. Short- Prolonged ; frequently as long or longer 
ened in duration. Rapidly evolved. than the inspiration. Generally more in- 

tense than the expiration. Rarely absent. 
Pitch higher than that of the inspiration. 
An interval between inspiration and ex- 
piration. Sometimes present without in- 
spiration. 

Broncho-vesicular Respiration. 

Inspiration. Expiration. 

Tubula;: and vesicular qualities mixed. Prolonged. Generally more intense than 

Pitch raised. Duration frequently short- the inspiration, and the pitch higher. Usual- 

ened. ly present. Pitch somewhat higher than 

that of inspiration. An interval between 
inspiration and expiration. Sometimes 
present without inspiration. 

Cavernous Respiration. i 

Inspiration. Expiration. 

Blowing or non-vesicular in quality. Feeble. Frequently absent.(?) Pitch 
Pitch low. Slowly evolved. lower than that of inspiration. 



The remaining division of the modifications in quality, etc., of re- 
spiratory sound comprises those relating to rhythm. The subdivi- 
sions under this head, save one, are among the constituent elements 
of modifications included under other divisions, and have been already S 
considered. A brief notice of them will therefore suffice in the pre- ^ 
sent connection. The modifications in rhythm which are of import- |; 
ance in diagnosis are three in number, viz., 1, shortened inspiration; ) 
2, prolonged expiration ; 3, interrupted respiration. The two first 
have received attention in connection with exaggerated, feeble, bron- 
chial, and broncho-vesicular respiration. 

7. Shortened inspiration. — Abnormal shortening of the inspiratory f 
sound, occurring as one of the elements entering into modifications ji 
which have been considered, is of two kinds. As it is presented in i 
the feeble respiration incident to emphysema, it forms what is called I 
deferred inspiration. The inspiratory sound does not commence prior !i 
to the middle or toward the close of the inspiratory act. Hence the '^ 
propriety of the term deferred. With the ear applied to the chest, 
the expansive movement is frequently felt for some time before any i^ 
sound is appreciable. The healthy vesicular murmur is heard in 
health with an intensity increasing from the beginning to the end of 



AUSCULTATION IN DISEASE. 211 

the inspiratory act. When, therefore, the sound becomes abnormally 
feeble in emphysema, it is inaudible until the intensity increases to a 
certain point. In this way, with the progress of the disease, it is in 
some instances at length extinguished; the suppression extending 
more and more towards the end of the act of inspiration, until the 
sound entirely disappears. The duration is diminished in a different 
manner in the bronchial and the broncho-vesicular respiration. The 
sound is quickly evolved, commencing nearly at the commencement 
of the act of inspiration, and ends before the close of the act. The 
inspiratory sound in this case, is said to be unfinished. The differ- 
ence in these two forms of shortened inspiration, it will be observed, 
corresponds to the difference as respects the situation in which the 
sound is generated. A vesicular inspiratory murmur when shortened, 
is deferred ; a shortened bronchial inspiration is always unfinished. 
Another point of distinction is involved in the foregoing, viz., a 
shortened bronchial or unfinished inspiration is, at the same time, 
notably changed in quality and pitch ; a shortened vesicular or de- 
ferred inspiration offers much less change in other respects. To treat 
of the diagnostic significance of this rhythmical modification, would 
be to repeat what has been already fully presented. 

As the consequence of an unfinished inspiration, an interval occurs 
between the inspiratory and the expiratory sounds. The duration of 
this interval is proportionate to the extent to which the inspiration is 
shortened. Regarding this as a distinct modification of rhythm it is 
called divided respiration. Division of the two sounds of respiration 
is one of the several elements of the bronchial and the broncho- 
vesicular respiration. It is a change, however, entirely dependent on 
the unfinished duration of the inspiratory sound, and it suflSces to notice 
it as incidental to the latter. 

8. Prolonged expiration. — Although Laennec did not overlook the 
fact of the existence of an expiratory sound in health, the importance 
of its abnormal modifications escaped the attention of the illustrious 
discoverer of auscultation. His observations of the phenomena of 
disease referable to modified respiratory sounds, were confined to 
those produced by the inspiratory act. The honor of having first 
called attention to the value of the expiration in physical diag- 
nosis belongs to an American physician, arrested by the hand of 
death at the threshold of a career of useful labor in behalf of medi- 
cal science. In 1833, Dr. James Jackson, Junr., of Boston, at 
that time prosecuting his studies in Paris, communicated a paper 



:| 



212 PHYSICAL EXPLOEATIOX OF THE CHEST. 

to the Sociefe 3IedicaU d' Observation, on the subject of a prolonged 
expiratory sound as an early and prominent feature of the bronchial 
respiration, and frequently constituting an important physical sign of 
the first stage of phthisis. From this epoch may be dated the com- 
mencement of observations which have rendered the expiratory 
scarcely inferior to the inspiratory sound, in its relations to the dis- 
tinctive characters of the bronchial, the broncho-vesicular, and the 
cavernous respiration. The reader has only to glance at the tabu- 
lar view of the characters distinguishing severally the modifica- 
tions just mentioned, to perceive the importance of the abnormal 
changes in duration as well as in the intensity and pitch of the soimd 
of expiration. A prolonged expiration has been also seen to enter 
into the characters distinguishing exaggerated respiration, and to con- 
stitute a striking feature of the opposite, viz., feeble respiration as 
exemplified in certain cases of emphysema. 

Differences in other particulars than duration, and especially varia- 
tions in pitch, are important to be considered in connection with pro- 
longation of the inspiratory sound. Thus, in bronchial respiration, 
the expiration, while it is increased in length, is more intense and 'li 
higher in pitch than the sound of inspiration. The same difi'erence -'^ 
holds good, to a greater or less extent, in broncho-vesicular respira- 
tion. On the other hand, in cavernous respiration, the expiratory 
sound is more feeble and lower in pitch than the sound of inspiration. 
In exaggerated respiration, the expiration is also less developed than 
the inspiration, and the relatively lower pitch which exists in normal 
respiration is preserved. The same is probably true of the prolonged 
expiration in emphysema; at all events, it does not present the eleva- 
tion of pitch which characterizes the expiratory sound in bronchial 
respiration.^ These variations in the pitch of the expiratory sound 
have hitherto been but little studied, and their significance has, there- 
fore, not been sufficiently appreciated. They appear from the facta 
just stated to sustain relations to the differences in the physical con- 
ditions under which the duration of the expiratory sound is increased, 
which it is both interesting and important to note. When the pitch is. 
raised in the bronchial and the broncho-vesicular respiration, the pro- 
longation is due to increased density of lung ; while in exaggerated 

^ The prolonged expiration in emphvsema often assumes a high-pitched tone in con- 
sequence of co-existing bronchitis. Under these circumstances it ceases to be, properly 
considered, a modified respiratory sound, but becomes a rale. This distinction is to be 
observed in verifying by observation the statement made above. 



AUSCULTATION IN DISEASE. 213 

j respiration there is no morbid change in the part of the lung whence 
I the sound emanates, but simply an increased functional activity, and 
i under these circumstances the pitch is not raised, but continues as in 
health, lower than that of the inspiration. In emphysema, owing to 
the diminished elasticity of the lung, the cells collapse and expel 
their contents more slowly than in health. In this case the pitch is 
not notably, if at all raised. The same will be true when the pro- 
longation is due simply to any obstruction to the passage of air from 
I the cells to the larger bronchial tubes. If this view of the subject 
I be correct, and observations will, I believe, be found to confirm its 
j correctness, the pitch of sound, taken in connection with increased 
j duration, affords a means of determining whether the latter is an 
indication of tuberculous or other morbid deposit, or only of a retarda- 
tion of the reflux current of air from the cells. 

A prolonged expiratory murmur in some instances is the sole or 
chief alteration of the respiration which an examination of the chest dis- 
I closes, the inspiratory sound not presenting any distinct morbid change 
j in vesicular quality, intensity, pitch, or duration. Now, what is the 
* diagnostic value of a prolonged expiration under such circumstances ? 
The importance of this question relates to its practical bearing on the 
diagnosis of incipient phthisis. Is a prolonged expiration under the 
circumstances assumed, to be regarded as a sign of tubercle ? These 
inquiries suggest some considerations to which I will devote a little 
space. The earliest and most obvious of the auscultatory evidences 
of tubercle, in a certain proportion of cases, undoubtedly, are inci- 
dent to the expiration. On this point, the observations of Dr. Theo- 
philus Thomson are interesting.* This author states that among 
2000 consumptive patients, a prolonged expiratory murmur was the 
most remarkable of the physical signs in 288, or a proportion of about 
one to seven. In a large majority of these cases, the concomitant signs 
and symptoms were not such as to render the diagnosis positive ; and, 
hence. Dr. Thomson is led to conclude that a prolonged expiratory 
murmur frequently takes precedence of other characteristic signs; 
an opinion according with that advanced by Jackson, in his memoir 
on this subject. But a prolonged expiratory murmur is found to exist 
frequently in the healthy chest. This is shown by the results of a 
series of examinations given under the head of Auscultation in Health. 
A certain allowance is to be made for this fact, which was not ascer- 
tained when Jackson first called attention to the importance of the ex- 

* Clinical Lectures on Pulmonary Consumption. 



214 PHYSICAL EXPLORATION OF THE CHEST. 

piration in diagnosis, and hence, he was naturally led to overrate the 
intrinsic siornij&cance of the sio-ii under consideration. There is reason 
to suspect that in some of the cases examined by Dr. Thomson the 
prolonged expiration may have been a natural peculiarity. The sub- 
jects were the out-patients of an hospital, and it is not stated how 
large a proportion remained under observation till the evidences of 
tuberculous disease were unequivocally declared. A naturally pro- 
longed expiration, however, occurs only on the right side. The ques- 
tion whether it be natural or morbid, therefore, arises only when it 
is found on the right side. Existing on the left, and not on the right 
side, the significance is vastly greater than when the reverse is the , If 
case, or it is found on both sides. It is needless to say that its sig- Mi 
nificance as a sign of tubercle depends on its situation at the summit 
of the chest. If it exist more or less over the entire chest on one 
side, still more on both sides, it is due to other causes than tubercu- 
lous disease, and, if not natural, probably denotes emphysema. The 
more circumscribed the space over which it is heard at the summit, 
the greater the diagnostic evidence of tubercle. The evidence, also, 
is enhanced if it be found in a circumscribed space in the infra- 
clavicular region at some distance from the point at which the normal 
bronchial respiration is to be sought for, and is more marked than in 
the latter situation. Finally, the elevation of pitch is to be taken 
into account. If the pitch be not raised, it indicates only obstruc- 
tion, which, it is true, may be incident to tubercle, but inasmuch as 
other causes may induce obstruction, the evidence of phthisis is less 
if the pitch remains unaltered. Among cases in which a tuberculous 
deposit actually exists, it must be exceedingly rare that the diagnosis 
hinges exclusively on a prolonged expiration. It would certainly be 
unsafe ever to base a positive diagnosis on this sign alone. In con- 
junction with other signs, however, and with symptoms, observing the 
cautions just mentioned, it is entitled to considerable weight. In 
a large proportion of cases, it is associated with more or less of the 
other characters of the bronchial, or the broncho-vesicular respira- 
tion, of which modifications, when it co-exists with tubercle, it is to 
be regarded as a constituent element. 

It is necessary to caution the inexperienced auscultator against 
mistaking for a prolonged expiratory murmur the sounds originating 
in the mouth, throat, or nasal passages, entering the ear not applied 
to the chest, and appearing to come from the chest. 

9. Interrupted respiration. — This rhythmical aberration has re- 



AUSCULTATION IN DISEASE. 215 

ceived several names, such as jerking^ wavy^ cogged-wTieel} The 
sound instead of being continuous, is broken into one or more parts. 
It may be imitated in the mouth by drawing in the breath with a 
series of disconnected inspiratory efforts, instead of a single uniform 
act of inspiration. It is very rarely observed with expiration. 

The inspiratory sound may be interrupted in connection with vari- 
ous affections, which may be arranged into two classes, according to 
the mode in which they produce this phenomenon. In one of these 
classes the interruption takes place in consequence of a corresponding 
want of continuousness in the expansive movements of the thoracic 
walls. This occurs in pleurisy, pleurodynia, and intercostal rheu- 
matism, in consequence of the pain occasioned by expanding the 
chest. The patient instinctively, as it were, shrinks from the move- 
ments necessary to haematosis, and hence an irregular series of efforts 
instead of a steady expansion. Thus produced, an interrupted in- 
spiratory sound will pervade the entire chest. In the other class, the 
cause is seated in the pulmonary organs. In the latter case the sign 
is limited to a part of the chest. When the cause is pulmonary, it is 
of a nature to oppose an obstacle to, but not to prevent, the free ex- 
pansion of a portion of the lungs. Partial obstruction of a bronchial 
tube, either from spasm, tuberculous deposit, or bronchitis confined 
within circumscribed limits, is probably competent to produce this 
effect. Adhesions of the pleura, also, may involve the necessary 
physical conditions. 

This exists as a normal peculiarity in a certain proportion of in- 
dividuals, who, irrespective of this sign, are apparently free from pul- 
monary disease. I met with it in two of twenty-four examinations. 
I have observed it on the healthy side in lobar pneumonia. Incident 
to health, it is sometimes a transient or intermittent peculiarity, but 
in some instances is persistent. In health or disease it is oftener 
observed on the left, than on the right side, and is rarely found, ex- 
clusive of the cases in which it extends over the whole chest, elsewhere 
than at the summit in front. 

The importance of this sign practically may be said to have refer- 
ence solely to the diagnosis of incipient phthisis. Observations show 
that it is present not infrequently in cases of tuberculous disease, at 
an early period, while the associated physical indications are slight. 
Under these circumstances it may, in some instances, be due to the 

' Called by Laennec inspiration entj-ecoupee, and by French writers of the present day 
respiration saccadee. 



216 



PHYSICAL EXPLOKATIOX OF THE CHEST. 



obstruction caused either by tke pressure of the tubercles on 
bronchial tubes, or by circumscribed bronchitis ; and in other instanei 
to mechanical restraint exterior to the lungs, such as is incident 
pleuritic adhesions. Its significance or value as h diagnostic sign 
phthisis, of course depends on the frec^uency with which it is observe 
in that affection, and its iufrequent occurrence in health, or in coi 
nection with other forms of disease. Dr. Theophilus Thomson, wl 
has made this sign the subject of special statistical research, recordc 
105 cases in which it was found to be present.^ Of these cas( 
in 32 there were grounds, irrespective of this sign, for suspecti 
tuberculous disease. Of the remainder, many were entirely frt 
from other evidences of any affection of the lungs. Dr. Thomsoi 
adds that in several instances he has watched the persistency of tl 
sign for years without its becoming complicated with any other in( 
cation of disease. 

In view of these facts an interrupted inspiratory sound cannot bej 
considered to afford more than a certain amount of presumptive evi-j 
dence of phthisis. As an isolated sign it is entitled to but little! 
weight. Associated with other signs, such as dulness on percussion,] 
prolonged expiration, etc., being present at the situation where th< 
latter are observed, and this situation being a circumscribed space 
the summit of the chest, it adds to the amoimt of collective proof 
the existence of a tuberculous deposit. 



2. A^jYEXTiTiors Eespieatoey Sounds. — Thus far, in treating 
the phenomena incident to respiration, the abnormal sotmds whic 
have been considered are modifications of those which pertain to 
respiratory apparatus in health. It remains to consider certain ph( 
nomena which have no existence in the healthy chest, and are then 
fore distinguished as new or adventitious sounds. The greater 
of these sounds originate either in the air-tubes, the vesicles, 
within cavities formed in the lungs. Some are produced exterior 
the pulmonary organs between the pleural surfaces. The latter 
termed attrition oi friction sounds. Different names are employe 
to designate the former. Laennec applied to them the word rdle^ 
which is still in vogue with the French, and also with medical writei 
and in conversational language, to a considerable extent in othe 
countries than France. Other names by which they are collectivel] 
distinguished are rJionchi and rattles. The two latter terms are nc 

- Op. cit. p. 161. 



AUSCULTATION IN DISEASE. 217 

only wanting in eupliony, but their signification is inappropriate when 
applied to some of the sounds embraced in this class. In the absence 
of a satisfactory substitute either of classical derivation, or from our 
own language, it seems to me preferable to retain the title adopted 
by the discoverer of auscultation. I shall accordingly make use of 
the term rdle in the sense in which it was employed by Laennec, viz., 
to denote any abnormal sound produced with the acts of respiration 
in the air-tubes and vesicles of the lungs, or within cavities formed 
in these organs.-^ Proceeding at once to a consideration of the rales, 
the points to be first settled are, the number which are to be recog- 
nized as constituting individual signs ; the method of classification, 
and the appellations by which they are to be distinguished severally 
from each other. Laennec determined the rales by their audible 
characters, and designated them after resemblances to other well- 
known sounds. Most of the rales discovered by him are still recog- 
nized, and the same appellations are generally retained. Andral 
proposed to divide the rales after their anatomical location in the air- 
tubes, vesicles, or cavities, and to distinguish them from each other 
by their conveying to the ear the sensation either of the presence or 
absence of liquid, the former being called moist, and the latter dry 
rales. ^ As a basis of classification this is convenient and advantage- 
ous. The appellations, however, in common use since the time of 
Laennec will continue to be employed, and they are so interwoven in 
medical literature that it would be undesirable to endeavor to substi- 
tute others, even were they in some respects preferable. Following, 
then, the plan of distribution according to situation, certain rales are 
produced within the air-tubes, the larynx, trachea, the two bronchi, 
and the subdivisions of the latter. Those produced within the larynx, 
trachea, and two bronchi, may be arranged into one class, and em- 
braced under the denomination of Tracheal Rales. Tracheal rales 
may be dry or moist. The latter proceed from mucus or other liquid 
collected in the portions of the air-tubes just named. As a general 
remark, they occur, excepting when they are transient, only as an 
efi'ect of the movements necessary to expel morbid products from 
these situations becoming ineffectual, from blunted perception and 

^ If the French term rdle be adopted, it should, I think, be anglicised, and I shall here- 
after use it as an English word. 

2 Skoda restricts the application of the terra rale to the sounds produced by liquid. 
The dry rales he calls simply sounds. The latitude of signification accorded to the 
rales, may, however, be settled fairly by conventional usage, and there is a convenience 
in a generic term applied to all new or adventitious sounds. 



218 PHYSICAL EXPLORATION OF THE CHEST. 

defective muscular power. The tracheal rales are therefore charac- 
teristic of the moribund state, or indicate generally that this state is 
nigh at hand. Constituting what is popularly known as the " death 
rattle," they are sufficiently loud to be heard often at a considerable 
distance, and indicate to the ear the presence of liquid. They are 
exaggerated types of certain of the moist rales produced within the 
pulmonary air-tubes. Dry rales may be produced within these sec- 
tions of the air-passages when there exists contraction at the glottis 
from spasm, oedema, exudation of croup, etc. ; or when, from the 
pressure of a tumor, the presence of a foreign body, morbid deposits 
or growths, the calibre of the tube is sufficiently diminished at a point 
below the glottis. They consist of wheezing, whistling, or crowing 
sounds, more or less intense, which may be audible at a distance, 
without stethoscopic examination. These sounds also represent, on a 
large scale, the dry rales produced within the pulmonary organs, and 
involve similar physical conditions. Auscultation of the larynx or 
trachea will sometimes reveal dry rales not otherwise audible, and, in 
either case, may be useful in determining the precise seat of an ob- 
struction. Rales produced within the larynx or trachea may be pro- 
pagated to the chest and heard in the latter situation. It is, there- 
fore, necessary sometimes to auscultate the larynx and trachea in 
order to determine whether sounds heard over the chest are trans- 
mitted from these sections of the air-tubes. It is chiefly in the two 
points of view just named, that tracheal rales are of importance in 
diagnosis. 

Adventitious sounds produced within the pulmonary subdivisions of 
the bronchi are called the Bronchial Rales. These are of two kinds, 
the one, indicating by the character of the sound, the presence, and 
the other, the absence of liquid in the bronchial tubes. The former 
are called moist, and the latter dry rales. The dry bronchial rales 
are subdivided into two varieties, called the sibilant and sonorous. 
The distinction between the sibilant and sonorous rales consists mainly 
in a difference of pitch. A sibilant rale is high-pitched, and as the 
name imports, is a whistling or hissing sound. A sonorous rale is 
low or grave in tone. The former, in general, is produced in the 
smaller, and the latter in the larger bronchial tubes. Both are some- 
times distinguished as the vibrating rales. Most of the moist bron- 
chial rales are usually styled mucous rales, the liquid concerned in 
their production being generally mucus. They are, however, pro- 
duced equally by other fluids, viz., pus, softened tuberculous matter, 



AUSCULTATION IN DISEASE. 219 

serum, or blood. They are subdivided into coarse and fine rales. 
The sound in the former instance conveying to the ear the idea of 
large, and in the latter of small bubbles. These variations are found 
to correspond to differences in size of the bronchial tubes in which the 
sounds are produced. In contrast with the term vibrating^ applied 
to the dry rales, the moist are sometimes called bubbling rales. 

A moist rale produced in the minute bronchial divisions, but not in 
the capillary bronchise, is distinguished as a sub-crepitant rale. The 
significance of this title is derived from resemblance to a sound pro- 
duced within the vesicles, to which reference will shortly be made. 
The sub-crepitant is an important variety of the moist bronchial rales. 

The only rale positively attributed to the air-vesicles is called the 
crepitant or crepitating ; so called from the peculiar character of the 
sound. This is a highly important physical sign. 

Crurgling is a name applied to a peculiar sound produced by bub- 
bling, and the agitation of liquid contained in a cavity of considera- 
ble size. By some, however, it is considered as simply a variety of 
mucous rale. 

In addition to the several rales just enumerated, there are certain 
sounds occasionally heard, undetermined as regards their location and 
the mode of their production, as well as somewhat varied in character. 
These may be embraced under the title indeterminate rales. 

By reference to the subjoined tabular view, the reader will be able 
to see at a glance, the number and names of the several pulmonary 
rales, which are to be subsequently considered, arranged in the order 
in which they have just been briefly described. 

Table slioioing tlie Numher, Names, and Anatomical Situations of the Pulmonary 

Bales. 

1. Bronchial. 

C 1. Sibilant rale. 

a. Dry, or vibrating. ^ 2_ g^^^^^^^ ^^j^^ 

r 1. Coarse mucous rale. 

b. Moist, mucous, or bubbling. -{ 2. Fine raucous rale. 



L 3. Sub-crepitant rale, 

2. Vesicular. 

3. Cavernous. 



1. Crepitant rale. 

1. Gurgling rale. 

4. Indeterminate. 

1. Rale crepitant sec d, grosses bulks, of Laennec. 

2. Pulmonary crumpling, 

3. Pulmonary crackling. 



220 ?zt5::ai sxplosatio:" :r izi :zz5r. 

1. S&UantraU. — Any brondual soheI. i i: :z; : _ : :'_- 
normal respiration, in ottiieor words, any s i :: : ^= sitimd or rale. 

■wIl::'!: ::"'"t~^ '" 'h& ear ttf ETLi::::;^ :: ..:-:. v: :_ " :^ acute or 

hii:::--"::: :-:7 "., : '': 'izider tfefi :.rL :ii:::: '_ : :_ _.: 



a crence <>r ^r~-.: :.: :-_:;.: ::.- ■::l:.\\ . :^::~ : 
resemMancf ': '::::;.: ~ .-_::: ^^i -: ■.:;..-, 

racteriaed : ~ : " : :"_^- : 1 ;lc~^:i:i- :: ^.:: 

definition. :: iaes^ it is appre: 

::z::->7, It : : „ : ~ ecmtinne to 

: : It '; r:::c ^-i" r: ■ .7 . : . _ :: _ ' ~ '^'^ masked 

I: :;„ ^ - ■ : : ; l: ■ ..." : '.. ; ...:::" ; : : L r t~:: iratorv a. 



ri _ 1 1 _ _ : in a certain part of the ches:. _ r 

Lri: _: _ : -^las dianging its seat, it m:- f- 

t1 "7. _ _ L - ^ :imc. The rale may be mc: t s 

7 1 oTer the entire ehest, or confined to one side, or, again, 
— — :: "/: .mnsdibed s^pace. 

r_7 ra!e is prodnced within tcr ^1: 7: ranches of the 

hr 1 Ijiis is the role, with p-: - :-©ptional instances 

in win: _ : : ^ 1 ihe larger hronc: 7 lence of their 

calihue; ^ i li. r . _ . : ^^ morbid chang t - _ . _ '- : -sitiibnted its 

producticm : ; : _ : s 7 : in the tubes I i 1 : _ : : : : : ed at cer- 
taiz. ': ::::-i - -~:ii::._: ": tLt zinooas ilti: : : :^i7. _:.:_:. :'= -airia- 

MiiiT. -i:~7"::. ::.:'. :'_- : ;- -':_-■- z^ ZT^--:iZ-\~ '.'' ::- '-'r:- 3T1 

act of ::;;.^L:i-, :: :^ ■::■;:■ ..:_ _.:.-- ::' ::. : ^. : :_:-.:. ::^ ::> 

tenacic:.^ 11:::.;.= :.'..[:.-: :_z '- '-7 "''i= :: '-7 ^-; 7= ""::_ 5 ~::7:.: 
firnuffifc-s ; : ; : : : :. ^ : ; 1 ■ ■ : : : i ; : : : .1 ; . 7 : : : _ t ;:::_: 1 : : : " ' 1 . ; . ~ -^ 
rise tc ;;:-;:::- ":".-:.:.: ^--::i:::: ':-:'_\'_:_:i:\ li.;; 7:;;" i^ ■;. ■ :: : :. is 



smaDer tnl-fs, "iirL :i_7 il:.\:^ ::t ::-:-'. :- ;_^iiL:i :. ■::!_:::" :: 
anre. The s". :_ : : t _ 1: :i t, z rater in some porri 



AUSCULTATION IN DISEASE. 221 

in others, reducing thereby the capacity of the tubes, not uniformly, 
but irregularly, may, it is probable, give rise to dry rales, which, under 
these circumstances, are more persistent. Spasm of the muscular 
fibres also induces the requisite physical conditions. So, also, pres- 
sure of a tumor on the tubes, diminishing their size, and changing 
their direction, but not sufficiently to produce obstruction. 

In the majority of instances a sibilant rale is a sign either of 
catarrh or bronchitis seated in the smaller tubes. If it be heard 
more or less over the chest on both sides, associated with certain 
symptoms, febrile movements, etc., the evidence is very strong of the 
early stage of capillary bronchitis occurring as a primitive affection ; 
for bronchitis is one of the symmetrical diseases, which is not true, 
to the same extent, of diseases in which bronchitis is liable to occur 
as a contingent affection. On the other hand, if it be confined to 
one side of the chest, it may be due to bronchitis occurring as a 
secondary affection, for example, in connection with pneumonitis or 
pleurisy. If it be restricted to a circumscribed space at the summit of 
the chest on one side, taken in connection with other facts, it inferen- 
tially points to the existence of phthisis ; for circumscribed capillary 
bronchitis rarely occurs except in the immediate vicinity of a tubercu- 
lous deposit, and it is at the summit of the chest, near the apex of the 
lung, that this deposit takes place. The sign is present in a marked de- 
gree in asthma proceeding from spasm of the bronchial tubes, generally 
associated with pulmonary catarrh or bronchitis ; and it is still more 
marked if the catarrh or bronchitis occur in connection with emphy- 
sema. Under the circumstances last m.entioned, it is most prominent 
in the expiration, owing to the same causes which occasion a prolonged 
expiratory murmur, viz., impaired elasticity of lung, and the neces- 
sity of increased muscular power to expel the air from the over-dis- 
tended cells. Although, therefore, the presence of the sign gene- 
rally denotes inflammation of the mucous membrane lining the smaller 
tubes, or irritation bordering on an inflammatory state, the diagnosis 
would often be incomplete were not other signs taken into account, 
as well as symptoms which disclose the coexistence of other affec- 
tions, viz., pneumonia, pleurisy, tubercle, and emphysema. It is 
only after excluding these several affections by the absence of their 
diagnostic criteria, that the sign denotes a morbid condition pertain- 
ing solely to the bronchial tubes. 

2. Sonorous rale. — This expression, which the French apply to all 
the dry bronchial rales, by English writers is limited to those dis- 



222 PHYSICAL EXPLOEATIOX OP THE CHEST. 

tmgmslied from the sibilant rale by gravity of tone. A sonorons rale 
may be defined to be any dry adyentitions sound produced witbin tbe 
broncMal tnbes, not acnte or bigb in pitcb. Tbe exact line of de- 
marcation between tbe sibilant and sonorous rales cannot be defined 
in words, nor is it necessary to make tbe distinction vith rigorous 
exactitnde in practice. Sonorons rales are dne to tbe same pbysical 
conditions as tbe sibilant, tbe only difiference as regards tbeir produc- 
tion pertaining to location. Tbey proceed from tbe larger broncbial 
tubes. In tbe:: \" 'f cbaracters tbey are not more uniform tban 
tbe sibilant raiv ^ -r__ : ng tbe diversity of sonnds to vrbicb tbey may 
be compared are tbe snoring of a person sleeping, beard at a dis- 
tance, tbe bnmminr " — usqnito, tbe cooing of a pigeon, a note 
of a bass-viol or b^-;:.:^. -:c., etc. Tbe tone is oftener more dis- 
tinctly musical tban tbat of tbe sibilant rales. Tbe sound is also 
londer and " : . : ^. -ometimes beard at a distance, "witbont 

anscnltatici.. .^^ ^. .^^„__^ a vibration or tbrill perceived by placing 
tbe band on tbe cbest. 

Tbe remarks in connection mtb tbe sibilant rale as to varial ". 
of intensity and peculiarity of tone, cbange of place, cessatioix ^-^•-. 
reappearance, and suspension by acts of congbing, are equally, and, 
indeed, even il . . jable to tbe sonorous rale. Like tbe sibilant, 

tbe sonorous la.- : ~ :":---" fitber act of respiration, or botb 
acts. Wben c-:'i:fiL- .: .- _ ire apt to be produced by expi 

ration, in : ^ :ular differing from tbe sibilant rale. 

Sonoro-i.^ . . "-:.-- !:!.-; - i'-_ • :. : - catarrb, or broncbitis, 

afi"ecting il~ . __ ; . . :l -.- . ~_.. ;_ _ ay be primary affections 

OT eomplieations of otber diseases, viz., pneumonitis, tubercle, empby- 
— :. ' etc. Tbe coexistence of otber morbid conditions is to be 
zTTiziinel by tbe £,,^^ociated signs, in conjunction witb symptoms. 
Oeeuj: :: . :l _ :. t :. witb otber diseases wbicb are oftener limited 
to one side oi' ibe cbesi tban primary catarrb or 1 : - it will be 

confined to tbe side affected; and bence, wben pr^i._. _. jotb sides, 
it is presumptive evidence tbat tbe broncbial affection is primary. 

Tbe sonorous and sibilant rales are often beard in combination ; 
tbat is, tbe sonorons existing at some parts of tbe cbest, and tbe 
sibilant at otber parts at tbe same moment ; or tbe two alternating 
mi irregular intervals witb successive acts of respiration in tbe same 
stuation ; or, again, botb appreciable at tbe same instant, sometimes 
commingled togetber, and sometimes succeeding eacb otber at differ- 
ent periods of a single respiration. Wben combined, it is evidence 






AUSCULTATION IN DISEASE. 223 

that the bronchial affection is seated both in the larger and smaller 
tubes. The sonorous, like the sibilant rale, is especially marked in 
cases of pulmonary catarrh or bronchitis occurring in connection with 
emphysema. It is in such cases that the sounds are sometimes so 
intense as to be heard at a distance. On applying the ear to the 
chest in the early part of these affections, or during a paroxysm of 
asthma, frequently a great variety of musical tones are heard, which, 
if auscultation be continued, are found to undergo constant mutations. 
They are sometimes continuous, not only during the two acts of respi- 
ration, but uninterrupted by the intervals between successive respira- 
tions, the contraction of the lung prolonging the sounds with expira- 
tion after the visible expiratory movements have ceased. In the 
progress of catarrh and bronchitis they diminish, or cease entirely, 
becoming merged in the moist rales to be presently considered. 

The discrimination of both species of the dry rales from other 
sounds emanating from the chest is attended with no difficulty. A 
mere description of their characters suffices for their recognition when 
heard for the first time. They are quite unlike any of the modifica- 
tions of the natural respiratory sounds, and are distinguished by 
points not less striking from other rales. As diagnostic signs they 
are important, indicating, as has been stated, in the great majority of 
instances, the early stage of bronchial catarrh or inflammations, affec- 
tions of frequent occurrence. As denoting these affections, their sig- 
nification is almost positive ; and if they are present extensively on 
both sides of the chest, together with the negative evidence afforded 
by the absence of the signs of other diseases, the diagnosis is com- 
plete. Pulmonary catarrh and bronchitis, however, not unfrequently 
occur as complications of other diseases. Under these circumstances 
the former are oftener confined to one side of the chest, or still more 
circumscribed, while the reverse is the rule when these affections are 
idiopathic or primary. But the fact of their existence as complica- 
tions is to be established by the concomitant signs and symptoms of 
the co-existing diseases. 

3. Mucous rales. — The mucous rales are the moist bubbling sounds 
produced in any portion of the bronchial tree except the minute 
branches, the sounds in the latter situation constituting the sub-crepi- 
tant rale. The term mucous is here used in a generic sense to com- 
prehend sounds, essentially similar in character, which are due to the 
presence of any liquid in the subdivisions of the bronchi. Mucus is the 
kind of liquid oftenest present; but other kinds are pus, blood, softened 



224 PHYSICAL EXPLORATION OP THE CHEST. 

tubercle, and serum. TYhenever either of these fluids is contained 
within the bronchial tubes, the currents of air with the respiratory 
acts, together with agitation of the liquid, cause explosive bubbles, 
which give rise to sounds more or less intense. These sounds have a 
bubblincr character, which is distinctive. In contrast with the rales 
abeady considered, they afford intrinsic evidence of the presence of 
a liquid ; in other words, the ear appreciates at once, the fact that they 
are moist rales. Differences in the quality of the liquid, as re- 
spects viscidity, etc., doubtless affect somewhat the character of the 
sound. The variations, however, due to this source are not sufficiently 
defined to serve as the basis of well-marked distinctions. So far as 
the audible characters are concerned, the only inference to be di'awn 
is, that liquid of some kind, in greater or less abundance, is contained 
in the bronchial tubes. Generally the kind of liquid is determined 
demonstratively by an examination of the matter of expectoration. 
The mucous rales may be imitated by blowing through a tube intro- 
duced into any liquid. 

The character of the sounds indicates the size of the tubes in which \ 
they are produced. In the larger tubes the bubbles appear to be of' 
greater volume : perhaps, the difference is in part owing to the space 
in which the explosions occur. At all events, the bubbling sounds 
differ perceptibly according to the dimensions of the bronchial sub- 
divisions in which they are produced. This has been shown by ex- 
periments in which, after death, sounds differing according to the size 
of the tubes are produced by injecting fluids into different sections 
of the bronchise, and afterward introducing currents of air by infla- 
tion.-^ These differences are expressed by the adjectives coarse and 
fine ; and the different degrees of coarseness and fineness are expressed 
approximately by words of quantity, such as veri/, considerable, mode- 
rate, etc. These expressions are sufficiently precise for practical pur- 
poses. The coarsest mucous rales, then, are produced in the largest 
bronchial tubes ; they lose this quality gradually in the subdivisions 
of these tubes, until in the smaller ramifications before reaching the 
minute branches, they assume the quality of fineness ; and this fine- 
ness merges into the still finer sub-crepitant rale. It would be diffi- 
cult to determine the particular locality at which the sounds cease to 
be coarse and become fine ; and it is equally difficult to draw the line 
of demarcation between the two classes of sounds with exactitude ; 
but such precision is of no consequence in diagnosis. 

• Earth and Rosrer. 



j AUSCULTATION IX DISEASE. 225 

i 

The mucous rales resemble the dry rales in variableness. They 
are liable to appear now here and novr there, shifting their seat from 
one part of the chest to another part ; occurring not with each respi- 
ration, but intermittingly in the same locality, and are often removed 
for a time by an act of expectoration. The bubbling sounds heard at 
; the same moment in a single spot may not be uniform. Bubbles of 
1 unequal volume appear to be commingled together. The sounds 
may be heard with inspiration or with expiration, or with both acts. 
; Finally, they may exist on both sides of the chest, or on one side 
; only, or in a circumscribed space on one or both sides. 
' In the great majority of cases mucous rales constitute the physical 
I sign of pulmonary catarrh or bronchitis advanced to the second stage, 
:^ or the stage of mucous secretion. The rales, other things being equal, 
i will be diifused over the chest, and intense in proportion to the extent 
' to which the irritation or inflammation pervades the bronchial mucous 
I membrane, and the abundance of the mucus secreted in consequence. 
j If fine and coarse rales are intermingled, which is not infrequently 
the case, it is evidence that the affection of the membrane is not con- 
fined to the larger tubes, but extends to those of smaller size. In 
I the progress of the affections just mentioned, the dry rales may 
i gradually disappear and give place to the moist ; but it is not infre- 
I quently the case that the former do not entirely cease, and the dif- 
! ferent varieties of the dry and moist rales are combined in various 

and constantly varying proportions. 
I In view of the fact that bronchitis and pulmonary catarrh affect 
the bronchial tubes on both sides of the chest equally, if mucous rales 
are found on the two sides, and especially toward the lower part of 
the chest behind, the evidence of one or the other of these affections 
is almost conclusive. The rales are most apt to be present, or to be 
more marked in the situation just mentioned, viz., at the lower part 
of the chest behind, on account of the larger number of bronchial 
subdivisions, the greater amount of inflammation in this situation, and 
also because, from their position, the removal of their liquid contents 
is effected less easily than from the tubes at the superior portion of 
the lungs. 

If, on the other hand, the rales are confined to one side of the 
chest, they denote a bronchial affection not primitive, but secondary, 
occurring, for example, as a complication of pneumonitis. Or they may 
be produced by the presence of liquid in the bronchial tubes irrespec- 
tive of any affection of the tubes themselves. Thus, pus in this situation 

t 

i 



22o PHYSICAL EXPLOEATION OF THE CHEST. 

may be derived from the pleural carity, the liver, or an abscess formed 
vrithin the pulmonary parenchyma ; the tubes may contain blood in 
cases of haemoptysis, or pulmonary apoplexy, or serum in bronchorrhcea 
and oedema. In all such instances the nature of the disease to which 
the mucous rales are incident, is to be determined by other associated 
signs and by symptoms. 

If the rales are confined to a circumscribed space at the summit of 
the chest ; or, even if they are more marked in this situation, and espe- 
cially if they are either present on one side only, or persistingly more 
marked on one side than on the other, they constitute a sign significant 
of phthisis, like the dry rales, particularly the sibilant, under similar 
conditions, and for the same reason, viz., they indicate a bronchi 
confined to a small section of the bronchial tubes. Thus restricted, 
the disease is never primitive, but dependent on a prior local affection, 
which affection, when the circumscribed bronchitis is situated at the 
summit of the chest, in the vast majority of cases, is tuberculosis. 
Mucous rales are apt to attend tuberculous disease in all stages of x 
its progress, being produced not alone by bronchitis occurring as a j 
complication, but by the presence of liquid derived from tuberculous 
excavations. Moreover, the bubbling and agitation of the liquid con- 
tents of small cavities occasion rales which cannot be distinguished 
from those produced within the large bronchial tubes. In general, 
mucous rales do not accompany, in a marked degree, tuberculous dis- 
ease prior to the stage of softening and excavation. 

4. Suh-crepitant rale. — By some writers, all the moist bronchial 
rales are embraced under this title ;^ and, on the other hand, the 
sub-crepitant might with propriety be regarded as a variety of mucous 
rale. A reason for making it a separate physical sign is, that ap- j 
proximating in certain of its characters to the rale produced within 
the air-vesicles, it is important to be discriminated from the latter. 
The name expresses the resemblance just referred to. The sub- 
crepitant rale forms an intermediate link between the mucous and the 
crepitant rales. It is distinguished from the mucous rales by its greater 
degree of fineness. It is produced in the minute bronchial ramifica-. 
tions, but not in the capillary bronchi. Its locality accoimts for its 
being finer, that is, for the bubbling being smaller than other bronchial 
rales. The bubbling character of sound is however preserved ; the 
sensation conveys the idea of the presence of a liquid in tubes of 
small dimensions. The bubbling soimd is generally unequal : in 

^ Birth and Roger. 

I 



AIJSCULTATION IN DISEASE. 227 

other words, it seems to be made up of bubbles uniformly small, but 
of different volumes. This character is due to the fact that the subdi- 
visions in which the rale is produced, although minute, are not of the 
same calibre. It is heard in inspiration and expiration, with either 
or with both. It may continue during the whole duration of the in- 
spiratory or the expiratory sound, or be heard only during a small 
portion of one or both of the respiratory acts. 

In its persistence it presents somewhat of the irregularity and want 
of uniformity which characterize the mucous rales, but its variable- 
ness is less marked. These few points are important to be borne in 
mind with reference to its distinctive characters as contrasted more 
particularly with the crepitant rale. 

The sub-crepitant rale attends those affections in which a liquid is 
present in the minute bronchial branches. The liquid is different in 
different forms of disease, presenting the same varieties as in the case 
of the mucous rales, viz., mucus, pus, serum, softened tubercle, blood. 
These different liquids are present in the minute bronchial branches, in 
capillary bronchitis, pneumonitis, oedema of the lungs, phthisis, haemop- 
tysis, and pulmonary apoplexy. The sub-crepitant rale, therefore, is 
liable to occur in each of these diseases. So far as the audible characters 
pertaining to the rale are concerned, it is impossible to determine there- 
by the nature of the liquid giving rise to the bubbling sound. This as- 
sertion is in opposition to the views of Fournet, who describes a dis- 
tinct rale for each of the several affections just named. In this he 
is not followed by other auscultators, who regard the rale as essen- 
tially identical in all, although by no means uniform in every respect, 
even in different cases, and at different periods of the same affection. 
The discrimination of the different affections characterized by the 
presence of this sign, is to be based, not on intrinsic differences in 
the characters pertaining to sound, but on other circumstances to 
which I shall briefly allude. 

In capillary bronchitis the membrane lining the minute bronchial 
branches is the seat of inflammation. The inflammation may be 
limited to this section of the bronchial tubes, or it may affect, at the 
same time, the larger subdivisions. The sub-crepitant rale in this 
disease is due to the presence of mucus. It succeeds, and may be 
more or less intermingled with, the sibilant rale, and if the affection 
be not confined to the minute branches, also with the sonorous and 
mucous rales. Capillary, as well as ordinary bronchitis, affecting, when 
primary, both sides of the chest, the rale will be present on the two 



228 PHYSICAL EXPLORATION OP THE CHEST. 

sides, and especially at the base of the chest behind. This is an im- 
portant diagnostic point, inasmuch as the other affections to Tvhich 
the rale is incident, are usually confined to one side of the chest. A 
sub-crepitant rale at the base behind on both sides is almost con- 
clusive evidence of capillary bronchitis, as distinguished from pneu- 
monitis, in which the crepitant rale, in the great majority of cases, is 
present on one side only. But other evidence derived from physical 
exploration may be brought to bear on the differential diagnosis, ex- 
clusive of the characters distinguishing the crepitant from the sub- 
crepitant rale. In capillary bronchitis the percussion-resonance con- 
tinues clear, while in pneumonitis it becomes dull. In the former the 
sub-crepitant rale continues, and is replaced by the vesicular murmur; 
in the latter it soon diminishes or ceases entirely, and generally gives 
place to the bronchial respiration. These circumstances will aid in 
arriving at a positive conclusion in instances in which, judging from 
the intrinsic characters pertaining to the rale, there might be room 
for doubt. 

The sub-crepitant, however, as well as the crepitant rale belongs 
to the natural history of pneumonitis. It occurs in a certain propor- 
tion of cases during the stage of resolution, having been preceded by 
the crepitant rale, and the physical signs of solidification of lung. 
With the latter signs it is moreover associated. Under these circum- 
stances it constitutes the rhoncus crepitans reduz, or returning crepi- 
tant rale of Laennec. 

In pulmonary oedema the sub-crepitant rale is due to the presence 
of serous fluid within the minute bronchial branches. Occurring in 
connection with this rather rare form of disease, it is usually limited 
to one side of the chest ; is present on the posterior surface ; accom- 
panied with more or less dulness on percussion, and found in connec- 
tion with the ulterior morbid conditions upon which the production of 
oedema depends, viz., disease of heart, more especially blood changes 
leading to stasis in the pulmonary capillaries (as in fevers), or favoring 
serous transudation. These circumstances, together with the absence 
of more or less of the physical signs of pneumonitis, in addition to 
the characters distinguishing the sub-crepitant and crepitant rales, 
enable us to exclude the latter affection. 

In phthisis a sub-crepitant rale may be due to circumscribed capil- 
lary bronchitis in the vicinity of the tuberculous deposit, or it may 
proceed from the presence of liquefied tubercle in the minute tubes. 
In the first instance, it may occur early in the disease ; in the latter, 



i 



AUSCULTATION IN DISEASE. 229 

not until a later period, after softening has taken place. In either 
case its significance depends on conditions similar to those which 
render a sibilant or a mucous rale a sign of tuberculosis, viz., its situa- 
tion at the summit of the chest, within a circumscribed space. "With 
these conditions, a sub-crepitant rale is strongly indicative of the ex- 
istence of phthisis. 

In haemoptysis and pulmonary apoplexy the presence of liquid blood 
in the minute bronchial branches, may give rise to a sub-crepitant 
rale. It is, however, by no means a sign constantly attending these 
afi"ections. It is observed in but a certain proportion of cases, and 
is of small value in their diagnosis. Blood escaping from the pul- 
monary vessels either passes into the larger tubes, and is expectorated ; 
or it coagulates, constituting apoplectic extravasation ; both results 
doing away with the physical conditions necessary to develope the 
rale under consideration. 

The sub-crepitant rale is an important physical sign. From the 
mucous rales it is distinguished chiefly by the sensation which it con- 
veys of a finer bubbling sound. The characters which will be pre- 
sently found to mark the distinction from the crepitant rale are, the 
sense of a liquid, inequality in volume of the bubbles, its presence some- 
times with expiration, as well as inspiration. In some instances the 
approximation is so close to the crepitant rale that, it must be con- 
fessed, judged by intrinsic characters, it would not be easy practically 
always to make the distinction. 

5. Crepitant rale. — The crepitant, also called the crepitating and 
crepitous rale, is distinguished from the rales already considered by 
its origin. It is a vesicular rale ; but it is not produced exclusively 
within the vesicles. The anatomical relations of the air-cells and 
the capillary bronchi are such that they can hardly be isolated from 
each other; and, in fact, the physical conditions giving rise to the 
crepitant rale pertain equally to both. 

The character of the sound is well expressed by the term crepitating. 
Laennec compared it to the noise produced by salt in a heated vessel. 
Barth and Roger liken it to the crackling of a moistened sponge, 
expanding close to the ear after being forcibly compressed. Dr. 
Williams has suggested an excellent imitation, viz., the sound caused 
by rubbing a lock of hair between the thumb and finger close to the 
ear. Other illustrations might be cited, but these are sufficient, and 
the one last mentioned is available at any moment. Opportunities 
for studying the rale itself are sufficiently abundant everywhere, and 



230 PHYSICAL EXPLORATION OF THE CHEST. 

after a description of its characters, witli the comparisons just men- 
tioned, the student will have no difficulty in recognizing it the first 
time it is presented to his notice. As already stated, it bears a re- 
semblance to the sub-crepitant rale. The two rales approximate in 
their audible characters, but usually they are readily distinguished 
by their intrinsic differences alone, and always w^ith the aid of col- 
lateral circumstances. The peculiar traits by which the crepitant 
rale is characterized may be best exhibited by contrasting it with the 
sub-crepitant rale. The sound in the crepitant rale is a true crepita- 
tion, while in the sub-crepitant rale it is a fine bubbling, approaching 
to a crepitating character. With the common idea that in both in- 
stances the sound is caused by minute bubbles, it is usual to say that 
the crepitant is a finer rale than the sub-crepitant. It will presently 
be seen, however, that agreeably to the most rational explanation of 
the crepitant rale, it is not a bubbling sound. The crepitant rale, in 
fact, so far as the sound is concerned, belongs among the dry rales. 
It does not convey to the ear the sensation of the presence of a liquid. 
Laennec regarded it otherwise, and in conformity with the prevalent 
opinion respecting its mode of production, it is included in the divi- 
sion of moist rales. Laennec, however, undoubtedly confounded the 
crepitant and sub-crepitant rales, the points of distinction between 
the two having been indicated since his time. He designated the 
crepitant as the moist crepitant, but in describing its characters in con- 
nection with the diagnosis of pneumonia, he says, it " seems hardly to 
possess the character of humidity." Auscultators at the present day 
who attribute the sound to bubbles, nevertheless consider dryness as 
one of its distinctive features. The sound appears to be made up 
of a large number of minute crepitations, in all respects equal. In 
this point of view it differs from the sub-crepitant rale, which is 
composed of unequal sounds, owing to the bubbles taking place in 
tubes differing considerably in calibre. The equality of the multitude 
of minute sounds which combine to form the crepitant rale is due to 
the fact that the spaces in which they are produced are more uniform 
in size. The crepitating sounds are rapidly evolved, occurring, as 
it were, in puffs, resembling the noise produced by ignition of a small 
train of gunpowder, to which it has been aptly compared. The sub- 
crepitant, as well as the mucous rales, take place more slowly. 

In addition to the foregoing points which pertain to the audible 
characters, there are others not less distinctive. The crepitant rale 
is not variable. It continues constantly for a certain period, not 



AUSCULTATION IN DISEASE. 231 

changing with different respirations, save in intensity, and this is 
usually proportionate to the force with which respiration is performed. 
It is sometimes developed by forced breathing when it is not other- 
wise appreciable. It is not suspended by coughing and expectoration. 
On the contrary, after an act of coughing, the respiratory movements 
immediately succeeding being more forcible, it becomes more intense. 
Finally it is heard with the inspiratory act exclusively. This is cer- 
tainly the rule, and the exceptions, if they exist, are extremely rare. 
This last point, to which attention was first called by Dance, is emi- 
nently distinctive ; the sub-crepitant rale, as well as the mucous rales, 
being present frequently in the expiratory, as well as the inspiratory 
act. This point, as will be seen presently, has an important bearing 
on the explanation of the mechanism by which the rale is produced.^ 

Laennec regarded the crepitant rale as almost pathognomonic of 
the early stage of pneumonitis. At the present time, its distinctive 
characters having been more clearly defined, it is even more significant 
as a diagnostic sign than heretofore. A true crepitant rale is very 
rarely observed except in the early stage of pneumonitis. Moreover, 
it is very rarely the case that it is absent during the career of that 
disease. The opinion of Skoda is in opposition to the latter state- 
ment. He declares that not only has he failed to find it present, but 
he has not often observed it. This is one of the extraordinary asser- 
tions enunciated by that writer. It is at variance with the observations 
of others, whose opportunities for studying this disease have been quite 
as extensive. For example, Grisolle, who has contributed the results of 
the numerical investigation of a large number of cases of pneumonitis, 
affirms that this sign was wanting in only four instances. M. Aran 
failed to discover it in only one of fifty cases. That it is not invari- 
ably present is undoubtedly true, but the experience of most ausculta- 
tors is united on the fact of its existence being the rule in the lobar 
form of pneumonitis. In the lobular form of children the rule does 
not hold good. Not only, therefore, is it, as originally claimed by 

' A pleural friction-sound sometimes bears a very close resemblance to the crepitant 
rale, so that, judged by the audible characters alone, the former may be mistaken for 
the latter. This I state from experience. Barth and Roger state this liability to error, 
as follows: " II est un autre bruit qui pourrait facilement induire en erreur une oreille 
peu exerc^e: \e frottement pleuretique est parfois constitu^ par une serie de petits craque- 
ments successifs, par une espece de crepitation inegale, que le rapproche du veritable 
rhonchus crepitant. C'est sans doute cette variety de bruit qui a fait dire qu'il existait 
un rah crepitant dans la pleuresie.''^ P. 149. 



^3 PMTaeiCAly SXFK^KATEOSr 

IsBfc l&SB gqffle ig fes B H iSmM ifemiBsez i 
^iB <ffi^ga^8BgL £& irnggsg; easss «f &aBi& per .: 

apwHBMiB ami ^ae fawmcflfiiiil hk : 

Ttfea cHaa^ffisi to a^Sffittnil aieaaaigiiiB feeaMy kn . i T.- 
lfc dfertei iMKtamil ite ^wraoc ipall^, it b e :_ 

M%ai:tfte oiieridbe 

iS;is: 
Tbe i *« . "iwifi»BM in ndndk ift; is fiHHid m tlie oiiBMiriir?' 

agrawsaln 

if ^e 
,, xox. jf,,«»,«infflfe„ m tibfis iiasit MapgiLw «£* cases. 

wa^ Bmwit SBane wnBBe intcttitier t» xs^Kri. i& as a car f^. i 

if i^ iBe laresasii: mt li^ vs^raw mi&ce ^ de cfe«C(m 

iiie -moMmw^ wrfeipg caa asms aiieu ^oe fftan^^PCT aoe e^sseiry orrgisEiL l^t ■< 




AUSCULTATION IN DISEASE. 233 

combined. Capillary bronchitis and pneumonitis are sometimes as- 
sociated. In a case of this description which recently came under 
my observation, the fact of the concurrence of the two diseases 
having been demonstrated after death, the sub-crepitant rale 
existed on both sides, but on one side the sub-crepitant and crepitant 
rales were distinctly appreciable during the same inspiration, the 
former during the first part, and the latter at the close of the act. 

The returning crepitant rale, rdle crepitant de retour, described 
by Laennec as characterizing the resolution of pneumonitis, occurs in 
only a certain proportion of cases. It denotes the presence of liquid 
in the smaller bronchial branches, and is a sub-crepitant rale. This, 
in fact, with our present knowledge of the two rales, is a fair infe- 
rence from the description by Laennec. The occurrence of the sub- 
crepitant rale at this stage of pneumonitis has already been men- 
tioned. 

In the vast majority of cases, the crepitant rale denotes pneumo- 
nitis. It is not, however, true that it never occurs in any other affec- 
tion. It has been observed in oedema, and possibly in hsemoptysis. 
In these affections, the rale is generally a sub-crepitant, but the 
presence of serum, and perhaps of blood, in the air-cells, may give 
rise to a rale essentially similar to the true crepitant of pneumonitis. 
In haemoptysis, the expectoration of blood settles the diagnosis. 
Moreover, in this case the rale will be found at the summit of the 
chest in front, and not on the posterior surface, as in the larger pro- 
portion of cases of pneumonitis, haemoptysis being generally incident 
to tuberculous disease. The differential diagnosis of pneumonitis 
and oedema, is to be based on the associated circumstances which will 
usually suffice for discrimination without much difficulty. (Edema is 
comparatively rare. It occurs in certain pathological connections, 
and is unattended by the symptoms which usually accompany an 
attack of pneumonitis. 

A crepitant rale, at the summit of the chest on one side in front, 
confined within a circumscribed space, is a significant sign of phthisis. 
Primitive pneumonitis, in the adult, as already stated, generally in- 
vades an entire lobe, and in the great majority of instances, an infe- 
rior lobe. When situated toward the apex of the lung, and extending 
over a small area, the pneumonitis is secondary, and the antecedent 
affection is probably tuberculosis, inflammation having been developed 
in the immediate vicinity of the tuberculous deposit. This rale, with 



234 pet:::.^. 1 zxploratiom of the czz^r. 

the conditions just stated, becomes a sign of phthisis like the sibilant. 
the mucous, and the sub-crepitant rales, under sinular circumstances. 
The explanation of the mechanism by which the crepitant rale is 
produced, given by Laennec, and generally received at the present 
time, attributes it to the formation of minute bubbles within the 
Yes: :^-f = . " :id terminal bronchial tubes. According to this theory the 
m c :_ 1- i - -1 is precisely similar to that involved in the production of the 
mucous and sub-crepitant rales, the difference in the audible characters 
being supposed to be owing to the smaller size of the spaces in which 
the bubbling takes place. This explanation is unsatisfactory, in view of 
several facts pertaining to the characters distinctive of the crepitant 
rale. The absence of humidity, in other words, the dryness of the 
sound ; the constancy of the rale during the period of its continuance, 
and especially its accompanying exclusively the act of inspiration, 
militate strongly against the doctrine commonly held. To meet these 
objections, Dr. Wakhe suggested that the sound may be due to the 
sudden pressure exerted on exudation-matter between the vesicles, 
by the expansion of the lung. But the exudation in pneumonitis is 
within the air-cells, and, hence, in so far as the sound depends on 
this result of inflammation, it must be intra-vesicular. The nis: 
rational theory, and the one which meets best the objections to that 
of Laennec, was offered several years ago, by Dr. Carr, of Canan- 
daigua, N. Y. Dr. Carr attributes the production of the sound to 
the abrupt separation of the walls of the cells, which had become 
adherent by means of the mucus, or the viscid exudation incident to 
the early stage of inflammation.^ That this explanation accounts 
for the peculiar, dry, and crackling sonnL as e^ zl by Dr. C, a 
simple experiment wiU serve to iUusr: :r. I: :_~ ' and finger 

be moistened with a little paste, or sol :.:: :_ : : ^— and. while 

held near the ear, alternately pinched together, :_ r ti. an 

imitation of the crepitant rale is produced more . :: :: i : li 
rubbing a lock of hair, as proposed by Dr. Williarr = . A vi^ ' r > 
dation within the cells and minute bronchise belongs among It . : :al 
phenomena of the disease; and as it is not readily remove ~ ex- 
pectoration, but accumulate till the cells are filled, and :Ef la^g 
solidified, the constancy of the rale for a certain duration is intel- 
ligible. Its occurrence with inspiration only, is fully explained by 
this theory. The conditions for the production of the sound are 

^ Xt " rx- sanation of Ae crepitant rhoodios of pneumonia, cr E. A. Caxr. MJ). — 
An 7 ; mal of Medical Sciences, Octobei^ 1842. 



AUSCULTATION IN DISEASE. 235 

only present after the lungs have collapsed with expiration, at the 
moment when the agglutinated walls of the vesicles are separated 
with the expansion of the lung by the inspiratory act. Adopting 
Dr. Carr's explanation, it would be expected, as observation shows 
it to be true, that the sound would be present in the early stage of 
pneumonitis, the air in this stage still entering the vesicles, and sub- 
sequently cease, nearly or entirely, in proportion to the extent and 
completeness of the subsequent solidification. The fact that when 
solidification has taken place, a certain number of cells are not filled 
with the morbid exudation, and remain in the condition which cha- 
racterizes all the cells in the early stage, explains the persistence of 
the rale in some cases during the second stage of pneumonitis, and its 
being developed, under these circumstances, by forced inspirations, and 
especially at the end of the inspiratory act. The theory of Dr. 
Carr is also equally applicable to the cases of oedema and hsemoptysis, 
in which the crepitant rale is observed. In these affections the vesicles 
contain a glutinous liquid, although in a less marked degree than in 
pneumonitis ; and we can readily understand that the necessary phy- 
sical conditions are present sometimes, but not constantly, on account of 
the greater facility with which the liquid escapes from the cells into 
the bronchial tubes, giving rise to the bubbling rales — the sub-crepi- 
tant and mucous. 

In view of the pathognomonic character of the crepitant rale, and 
the uniformity with which it attends the early stage of pneumonitis, 
it was justly considered by Laennec to be one of the most important 
of the physical signs. In its diagnostic value as an isolated sign it 
is entitled to the first rank among the phenomena furnished by aus- 
cultation. 

6. Cavernous Male, or Grurgling. — The entrance of air into a cavity 
partially filled with liquid, gives rise to a sound resembling a mucous 
rale produced within the larger of the bronchial tubes, from which it 
cannot always be distinguished ; and hence, according to some writers, 
it is needless to describe a cavernous rale as an independent physical 
sign. In some instances, however, the sound is sufficiently distinctive 
to indicate very clearly the existence of a cavity, and therefore it is 
entitled to a separate place among the phenomena of auscultation. 

A cavernous rale is a moist sound, conveying very distinctly the 
idea of a liquid. It is produced partly by bubbles, and in part by 
the agitation of the mass of liquid. The bubbles, in cases in which 



236 PHYSICAL EXPLOKATIOy OJ THE CHEST. 

the cliaracteristic Boimd is veil-marked, appear to be larger in size 
than the coarsest mncons rale, and, at the same time, fever in ninnher. 

The liquid thrown into agitation hj the impulse of the air, canses 
a sound, of -vrhich the best description is embraced in the term gnr- 
gling. It may be compared to the sudden commotion vhich occmB 
from time to time, vhen a liquid is brought nearly to the point of 
ebnUition. The latter is an occasional variety of the caTemons rale, 
and is presented in the most marked degree vhen the communication 
of the caTity vith a bronchial tube is sufficiently large for a column 
of air of considerable size to enter -with force, other f arorable physical 
conditions also coexisting. The movements of the lung, irrespectiye of 
the entrance of air into the caTity, it is probable may suffice to pro- 1 
dnce a gurgling sound, but less in degree. The impulse of the heart 
sometimes causes sufficient agitation of the liquid to gire rise to a 
rale, vhich is determined by obserring that it continues vhen respi- 
ration is momentarily suspended, and is synchronous vith the pulse. 
This curious fact has been repeatedly noticed when the caTity was 
seated in the left lung, but Dr. Stokes has obserred it eTen on the 
posterior surface of the right side of the chest. Tfee feabttog amil 
gurgling sounds may take place with inspiration and eBpiraiacm, cqbi- 
jointiy or singly, and vhen with either separately oftener -with the 
former act. The intensity of sound is sometimes so great, that it is 
heard at a distance from the patient. The reTerberation "within the 
space, aboTe the leTel of the liquid, occasionally giTes rise to a 
metallic or amphoric tone. 

The cavernous rale usually exists over a cireumBcrrbed space, on 
one side of the chest ; and inasmuch as excaTations are in the Tast 
majority of cases of tuberculous origin, its situation in forty-nine of 
fifty cases, is at the summit of the chest. The physical conditions 
necessary for the dcTelopment of the rale, when the caTity is partially 
filled, occasion the caTemous respiration vhen the cavity is empty. 
These two signs wHl therefore be found in certain cases to occur in 
alternation, and will serre mutually to confirm each other. 

A caTemous rale, depending as it does on seTeral circumstances, in 
addition to the e:nstence of a caTity, is by no means constant, and, 
in fact, is only occasionally discoTerable. The caTity must contain a 
certain amount of liquid, neither being empty, on the one hand, nor 
on the other hand, completely filled. The communication with tiie 
bronchial tubes must be below the leTel of the liquid. This commu- 
nication, and the bronchial tubes themselTes, must not be olstameted 



AUSCULTATION IN DISEASE. 237 

by morbid products. The concurrence of these conditions can only 
be expected to obtain now and then, so that we may auscultate for 
this sign repeatedly, in cases in which a cavity or cavities exist, with- 
out success. The value of the sign in diagnosis, therefore, is alto- 
gether positive ; negatively, it is of little or no value : that is, we are 
not authorized to infer the non-existence of a cavity from the absence 
of the sign. 

Other things being equal, the size of the bubbles and the loudness 
of the gurgling will be proportionate to the magnitude of the cavity. 
When the rale closely resembles the mucous, but retains the cavernous 
characters sufficiently to be distinguished from the latter, it has been 
called^ cavernulous, and supposed to indicate the existence of small 
excavations. This distinction, however, is clinically unimportant. 

As has been stated, a well-marked cavernous rale at the summit of 
the chest denotes almost with certainty, an excavation proceeding 
from tuberculous disease. But the rale may be present in cases in 
which cavities are otherwise formed, viz., from circumscribed gan- 
grene, abscess, and pouch-like dilatation of the bronchise. It may also 
exist in cases of perforation of the lung, with accumulation of liquid 
in the pleural sac, i. e. in pneumo-hydrothorax. The diagnosis of 
each of these affections must, however, be based mainly on other 
signs. The infrequency with which this rale is discovered, the diffi- 
culty in many instances of discriminating between it and coarse 
mucous rales (the two being, moreover, frequently commingled), to- 
gether with the fact, that it generally occurs at a period of disease, 
and under circumstances when the diagnosis is sufficiently easy, and 
has probably been already made, render it a sign of minor practical 
consequence. 

7. Indeterminate Rales. — Under this head may be embraced a 
variety of adventitious^ sounds, not clearly referable to either of the 
foregoing divisions, and of which the situations, as well as the man- 
ner of production, are matters of doubt. Notwithstanding this un- 
certainty as respects their locality and explanation, some of these 
sounds are by no means without value as physical signs, observation 
having established their pathological relations. 

(1.) Laennec described a distinct sound which he designated by the 
somewhat contradictory phrase, " Dry crepitant rale with large bub- 
bles" [rale crepitant sec a grosses hulles). This sound, according to 
Laennec, "conveys the impression as of air entering and distending 

' This title was first applied by M. Hirtz, of Strasbourg. 



^ 



238 PHYSICAL EXPLORATIOSr OF IHZ CHEST. 

lungs which had been diied, and :: - : :.: :_t : t _ ri -rsj 

equally dilated, and resembles the &<y::i t . ~ : : ~::. :. ::: 

dried bladder." He regarded the bc:.:. " :_ : " e ■ : : : ; t . ^ ; _ . 
istic of emphysema of the Irai^. I'l : : : -::::::. - \:i : ; : _ t : 

of Laeimec, have failed to discover a : t ^ t _ ^ r 
of the Hnd just stated ; and mnltipjieu ouSc. " : :: ; i - :_ ; : — : : 
physema, do not establish its connection with : _t s::_ s ^i I 
probable, that in instituting this rale, Laennec was infi:7 
preconceived notions. Having established a moist crepita::: 
was led theoretically to a^nme the existence here, as :_: 
instances, of a dry crepitant rale. At all events, if a rale, st 
Laennec described, exists, in view of the difficulty of appre:-:''i, 
and its indefinite signification, it is practicaJlj unavailable m ;_ 
nosis. 

Pulmonary crumpUng. — Under the title of/" 
naire, rendered as above, Foumet^ embraced a vsilt ~ : 
bearing to each other close resemblance, save tha:. 
observer, an impression is conveyed to the mi::: " :: :'^.z 
the "pulmonary tissue forcibly struggling sz"'-^: -:-1-t :._ _ 
to its expansion." One variety he ccc: - ' :1- i- - : : 
friction-sound (bruit de cuir neuf) heard in pr: . : . 
plaintive moaning-sound, with various intonati-:.ixS . : ^ :_ t. .:/. t 
sound produced by blowing upon tissue-paper. Ti— : = : : ':. 
ing so much in their audible characters, adni" :' ::lj ; :-f 
gether only as indeterminate rales. The bond :: ;i::i ^- : '. 
Foumet must 'be regarded as fanciful. The souni ItSth;.:::, 
crumpling of tissue-paper, and that of new leather, may be veii: 
pleural friction-sounds. The various moaning-somids ::t 77:' 
sonorous bronchial rales. Fournet endeavors to esta];L^_ ^ ;:_:■ 
distinction between them collectively and other rales, bnt the chief ^f 
characteristic is that by which they are placed in the same category, 
viz., the impression conveyed to the ear of a stm^le against an 
obstacle. Such impressions are so apt to originate within the mind 
that they are to be trusted but to a limited extent, in forming opinions 
respecting the explanation of auscultatory signs. 

It is chiefly with reference to the diagnosis of tubercnlons disease 
that the sounds regarded by Foumet as dependent on pulmonary 
crumpling are of practical importance. And their diagnc^c im- 
portance, in this relation, is irrespective of the question whether they 

' Op. cit 



AUSCULTATION IN DISEASE. 239 

are properly varieties of the same sign, and of any hypothesis as to 
their mode of production. Fournet states, that he has observed a 
hruit de froissement in the proportion of about one-eighth of persons 
affected with phthisis. Occurring at the summit of the chest, fre- 
quently, if not generally limited to one side, and confined within cir- 
cumscribed limits, a rale resembling either of the sounds above de- 
scribed, belongs among the numerous and varied physical signs which, 
from their situation and limitation, taken in connection with symp- 
toms, point to the existence of a tuberculous deposit. According to 
Fournet, these sounds are observed in the early stage of phthisis,* and 
the acute form of the disease, or tuberculous infiltration, is especially 
favorable for their development. 

Pulmonary crackling. — A crackling sound, presenting certain 
varieties {rdles de craquement), like the preceding, has been particu- 
larly described by Fournet, and is recognized as a distinctive ausculta- 
tory sign by most writers on the subject of physical exploration. The 
varieties of this sound are arranged in two classes, viz., dri/ crack- 
ling and moist crackling. Like the so-called crumpling sounds, they 
belong among the physical signs of phthisis, and are entitled to con- 
siderable weight in the diagnosis of that disease. Their diagnostic 
significance, like that of several other signs of tubercle already men- 
tioned, depends on their being observed at the summit of the chest 
within a circumscribed space. 

Dry crepitation bears a close resemblance to the crepitant rale. 
Like the latter, it appears to be made up of distinct crepitations, but 
much fewer in number, frequently, according to Fournet, not exceed- 
ing two or three. Like the crepitant rale, it occurs almost exclusively 
with inspiration. The mechanism of the sound is generally consi- 
dered doubtful. The most rational supposition, as it seems to me, is, 
that it is produced in the same way as the crepitant rale, viz., by the 
abrupt separation of the walls of a few cells which become adherent, 
when the lungs are collapsed, in consequence of the presence of a 
small quantity of glutinous exudation.^ The sound is occasionally 
observed during a few respirations in the healthy chest. In the 
twenty-four examinations to which reference was made under the 
head of Auscultation in Health, I met with it in two instances, in both 
of transient duration. It is a sign of rather frequent occurrence in 
the early stage of phthisis ; and, under these circumstances, is usually 

* This explanation accords with the description of the character of the sound by 
Fournet: "II consiste dans une sensation toiite particuli^re de rupture,"' etc. 



240 



PHYSICAL EXPLOEATIOX OF THE CHEST. 



constant during the period of its persistence. Of fifty-five cases, in 
which it was obserred by Foumet, its constancy was noted in all bnt 
nine instances. The crackling appears removed from the surface of 
the Inng, not near the ear, — a point which serves to distiaguish it from 
a pleural friction-sonnd. 

Moist crackling, according to Fournet, is developed at a later 
stage of the disease. The dry sometimes merges into the moist rale. 
Moist crackling appears to me to be neither more nor less than a 
sab-crepitant rale. As the title imports, it differs from dry crackling 
in its conveying the sensation of the presence of a liquid. It is not 
confined to inspiration, bnt occurs also in expiration. It is supposed ' 
by Fournet to indicate the transition of crude tubercle to softening, 
dry crackling pertaining to the period of crudity. It is probably 
due to the presence of fluid in the smaller branches of the bronchial 
tubes, and this fluid may be softened tuberculous matter, or mucous 
secretion from bronchitis affecting the smaller tubes within a limited 
area. The occurrence of the two kinds of crackling in regular suc- 
cession, and the uniform relation of each to a different stage of 
tuberculous disease, are theoretical conclusions which observation 
baB not conclusively established. 

The foregoing are the adventitious sounds included within the de- 
nomination of rales. The subjoined table contains a recapitulation 
of the distinctive characters, and diagnostic indications pertaining to 
them respectively. 






TaMe JEh^bUmg ^ Distmdwe Characters and Diagiwstk Indicatiotis 
of ike Different Bales. 



SlBILAVT. 

Diy sound, high, in pitch ; vrhistling, 
clicking : sometimes mnsical. 



YwaMe in contin-oance, intensity, into 
mflion, and situation. Suspended by congh- 



juspiratic^ or erpiration, 
cr Inch'; oftener "with inspiration. 

If px^nt on both sides, indicative of 
primiiive bronchitis or catarrh affecting the 
anialler tubes, or of bronchial spasm. 

Confined to one side, indicatire of catarrh 
or bronchitis complicating pneumonitis or 
pieunsf. 



SONOBOUS. 

Dry sonnd, grave in tone. Oftener 
musical than the sibilant; louder and 
stronger. 

Variable in continuance, intensity, into- 
nation, and situation. Suspended by cough- 
ing. 

Present with inspiration and expiratioii, 
oftener the latter, and with both. 

If present on both sides, indicative 
primitive bronchitis, or catarrh, or of bron- 
chial spasm. 

Confined to one side, indicative of secon- 
dary bronchitis, or catarrh. 



AUSCULTATION IN DISEASE. 



241 



Limited to a circumscribed space at the 
summit of the chest, indicative of tubercu- 
losis. 

Often associated with the sonorous and 
mucous rales. 

Mucous. 

Moist, bubbling sounds. Coarse or fine, 
in proportion to the size of the bronchial 
tubes in which they are produced. 

Variable in continuance, intensity, situa- 
tion, and degree of coarseness. Suspended 
by expectoration. 

Present with inspiration, or expiration, or 
both. 

Coarse and fine rales often combined. 

If present on both sides at the inferior 
posterior portion of chest, indicative of 
Ij second stage of primitive bronchitis or 
catarrh ; the coarseness or fineness denot- 
ing extent of bronchial tubes affected. 

Confined to one side indicative of secon- 
dary bronchitis, or the presence of pus, 
serum, or blood in bronchial tubes. 

Limited to a circumscribed space at the 
summit, or more marked in that situation, 
indicative of tuberculosis more or less ad- 
vanced. 

May be associated with sibilant and 
sonorous rales. 

Crepitant. 

Dry, crepitating sound. Evolved with 
rapidity, in puffs. Constant, not variable. 
Not suspended by coughing. 

Present with inspiration exclusively. 
Very rarely existing on both sides. 

Almost pathognomonic of the early stage 
of pneumonitis ; frequently continuing 
through the disease, or giving place to a 
sub-crepitant rale. 

Occurs occasionally in cedema, and 
hcemoptysis. 

Limited to a circumscribed space at the 
summit of the chest, indicative of tubercu- 
losis. 



Limited to a circumscribed space at the 
summit, indicative of tuberculosis. 

Often associated with the sibilant and 
mucous rales. 



Sub-crepitant. 

Moist sound, giving impression of very 
small bubbles. Bubbles somewhat unequal. 
More regular and constant than mucous 
rales. Less likely to be suspended by ex- 
pectoration. 

Present with inspiration or expiration, or 
both. 

If present on both sides at posterior in- 
ferior part of chest, indicative of primitive 
capillary bronchitis. 

Occurs in pneumonitis, at period of reso- 
lution ; also in oedema, and pulmonary 
apoplexy, or hsemoptysis. 

Limited to a circumscribed space at the 
summit of the chest, indicative of tubercu- 
losis. 



Cavernous. 

A moist sound, conveying the impression 
of very large bubbles, and the agitation of 
a mass of liquid (gurgling), occasionally 
synchronous with the heart's impulse. 

Present with inspiration, or expiration, or 
both, especially with inspiration. 

Sometimes accompanied with metallic 
reverberation. 

Generally situated at the summit of the 
chest. 

Alternating or combined with cavernous 
respiration. 

Ceases and returns at irregular intervals. 

Indicative of tuberculous excavations 5 
cavities following abscess, circumscribed 
gangrene, and pouch-like dilatation of 
bronchial tubes. 



16 



242 PHYSICAL EXPLORATION OF THE CHEST. 

Indeterminate. 

1. Rale crepitant sec cL grosses hulles. 

2. Pulmonary crumpling. 

3. Pulmonary crackling. 

Attrition or pleural friction-sounds. — With the act of inspi- 
ration the thoracic space is enlarged mainly by depression of the 
diaphragm, and the elevation of the ribs. The lung expanding to 
fill the augmented capacity of the chest, moves in a vertical direction 
downward, while the walls of the chest ascend ; and hence results, of 
necessity, a certain degree of friction of the pleural surfaces, which 
is repeated with the reverse movements of expiration. 

Normal pleural friction takes place silently, as shown by experi- 
ments on inferior animals, and auscultation of the healthy chest. This 
is undoubtedly owing to the highly polished and moistened condition 
of the membrane. When, however, the surfaces are rendered 
irregular and rough by morbid exudation or other causes, there exist 
the physical conditions for the production of adventitious sounds, to 
which are applied the titles attrition or friction sounds. The me- 
chanism of their production is sufficiently intelligible ; the points of 
inquiry which suggest themselves are, the diversity of the sounds 
thus produced ; their distinctive characters and the means by which 
they are to be distinguished ; the diseases to which they are incident, 
and the circumstances on which depends their diagnostic significance. 

The intrinsic differences of friction-sounds are such that they may 
be divided into several varieties. These, however, do not individu- 
ally sustain pathological and clinical relations, so distinct and impor- 
tant as to claim separate consideration. A delicate grazing is one 
variety, occurring when the opposing movements are not forcible, or 
the physical conditions are not the most favorable for the production 
of sound. Another variety is a more distinct rubbing^ chiefly denot- 
ing greater force of attrition. A greater degree of harshness of 
sound, dependent on greater roughness of the pleural surfaces, con- 
stitutes the variety called rasping or grating. A creaking^ like new 
leather, is still another variety. These diversities of sound are due 
to differences which are in a certain sense accidental, and may be 
presented in different cases of the same affection, without furnishing 
any special indications as respects either the nature or degree of the 
disease. The grazing and rubbing sounds, which are the varieties 
ordinarily presented, may be exactly imitated by placing the -palm of 
the left hand over the ear, with firm pressure, and moving slowly 



I 



AUSCULTATION IN DISEASE. 243 

over the dorsal surface, the pulpy portion of a finger of the right 
hand. 

A friction-sound may accompany both respiratory acts, or the act 
of inspiration alone. It is frequently heard with both acts, but very 
rarely limited to the act of expiration. When it accompanies both 
acts, it is more distinct with inspiration. It is seldom continuous 
during the whole of the inspiratory or expiratory act, but it occupies 
a portion only of its duration. Ordinarily, it is either a single 
sound of brief duration, or there occurs a series of sounds succeeding 
each other with more or less rapidity, resembling in this particular, 
interrupted or jerking respiration. Occurring in this manner it 
sometimes bears a very close resemblance to the crepitant rale, 
and may be mistaken for it. In some instances it continues unin- 
terrupted through the act of inspiration, and may even be pro- 
longed through the expiratory act, giving rise to a constant rumbling 
sound. In the great majority of cases, the sound is manifestly dry ; 
but it may suggest the idea of moisture. This occurs when false 
membranes, situated on the pleural surfaces, become infiltrated with 
serum. Under these circumstances a sound may be produced, which 
Walshe characterizes as squashy. The intensity is variable. It may 
be so slight as to be but just appreciable, or it may be so loud as to 
be heard at a distance. An instance has fallen under my knowledge 
in which it was so intense as to be a source of annoyance to the 
patient, during convalescence from pleurisy. Between these extremes 
there is every degree of intensity. It is usually confined to a small 
space, but it may be more or less difi"used, and occasionally is heard 
over the entire chest. In the latter case, it may be produced within 
a limited space, but its intensity causes it to be appreciable at a 
greater or less distance from its source. The situations where it is 
heard are usually the middle and lower portions of the chest, oftener 
laterally, or posteriorly. As exceptions to the general rule, it is 
sometimes heard at the summit, and thus situated, it has a special 
diagnostic significance, which will be presently mentioned. The sound 
always appears to be superficial, not emanating from beneath the super- 
ficies of the lung. This is a distinguishing feature. So superficial does 
it sometimes appear, that it seems to the auscultator to be produced 
upon the integument, and he is led by the apparent nearness of the 
sound, to suspect that a portion of the dress comes in contact with 
the ear or stethoscope. In some instances, a friction-sound is heard 
with each successive respiration, but oftener it is variable in this re- 



244 PHYSICAL EXPLORATION OF THE CHEST. 

spect, accompanying some respirations, but being absent in others. 
It is sometimes appreciable only with forced respiration, and, on the 
other hand, it has been observed to be strongest when the breathing 
was tranquil. The sound has been observed to be increased when 
firm pressure is made with the stethoscope. It is also variable in 
duration. It may be transient, or it may continue in a greater 
or less period. In a case reported by Andral, it lasted for three 
months. It is observed in some instances to shift its seat, being 
at one time heard at a certain point, and at another time in a 
different situation, and these changes may take place repeatedly. 
Intermittency is another point of variability. It may be present, 
disappear, and again reappear, and these alternations may occur more 
than once in the progress of the same disease. Finally, if a friction- 
sound be strong, and especially if it be rough, it is perceptible to the 
touch, on placing the hand over the side, as well as to the sense of 
hearing ; and in this way patients themselves become aware of a 
rubbing movement within the chest. 

The distinctive characters of a pleural friction-sound, are such 
that its discrimination is not generally attended with difficulty. The 
sound itself conveys the idea of its being produced by friction. In 
addition to this, its dryness, its accompanying frequently both re- 
spiratory acts, and especially its superficial situation, serve to distin- 
guish it from other adventitious sounds. As already stated, some- 
times, when interrupted and limited to inspiration, it may be mistaken 
for a crepitant rale. The instances, however, in which this resem- 
blance exists are rare, and the associated circumstances will generally 
prevent the error into which the auscultator might fall, were he to 
limit his attention solely to the character of the sound. In deter- 
mining the existence of a friction-sound, in all cases we are aided by 
the coexistence of other signs, and of symptoms involved in the 
diagnosis of the diseases in which it is known to occur. 

Dr. Stokes has called attention to the fact that a friction-sound 
may be due to the movements communicated to the adjacent portion 
of the pleura by the impulse of the heart. In this case, a friction- 
sound, in addition to that produced by respiration, will be found to 
be synchronous with the beating of the heart, or the pulse, and 
will continue when the respiratory movements are voluntarily sus- 
pended. The concurrence of a cardiac friction-sound, gives rise to 
the question whether it be of pleural or pericardial origin ; and the set- 
tlement of this question clinically, must be attended with considerable 



AUSCULTATION IN DISEASE. 245 

difficulty. In general terms, if it have been preceded, or if it be 
accompanied by the signs and symptoms of pericarditis, it is in all 
probability pericardial ; but if it be unattended by other evidences of 
an affection of the pericardium, and there are present the evidences 
of disease affecting the pleura, it may be suspected to have connec- 
tion "with the latter. 

A pleural friction-sound was regarded by Laennec as a pathogno- 
monic sign of interlobular emphysema. He did not, however, profess 
to have established this opinion on the evidence afforded by autopsical 
examinations, in cases in which the sound had been noted during life. 
Moreover, in the two instances given by him, in which he had ob- 
served this sign, the patients, if affected with interlobular emphysema, 
were also affected with pleurisy ; and it is remarkable that its connec- 
tion with the latter affection should not have presented itself to the 
reflections of the discoverer of auscultation. Subsequent observations 
have, shown that in the interlobular, as well as the ordinary form of 
emphysema, and also in that variety in which air-vesicles are formed 
by the elevation of a portion of the pulmonary pleura, a friction-sound 
is an exception to the general rule. Dr. Walshe has noted the 
occurrence of the sign in a few instances of the variety last named. 
With exceptions so infrequent that they belong among the curiosities 
of clinical experience, a friction-sound is indicative of pleuritis. It is, 
however, by no means a sign constantly or even frequently present 
in that affection, and, indeed, is observed but in a small proportion 
of cases. It may occur in different stages of pleuritic inflammation : 
first^ in the early stage, before the pleural surfaces are separated by 
liquid effusion ; and second, at a later period, after absorption of the 
liquid has taken place, and the pleural surfaces are again brought 
into contact with each other. In the early period of the disease it 
is due to the presence of coagulable lymph, with which, to a greater or 
less extent, the surfaces of the pleura are covered ; and according to 
Stokes, to abnormal dryness of the membrane, prior to the exuda- 
tion of lymph. That abnormal dryness precedes, as a general rule, 
the exudation of lymph, is not certain, and that it is alone capable of 
giving rise to a friction-sound, may be doubted. But however this may 
be, it is certain either or both these physical conditions, so seldom 
give rise to a friction-sound in the first stage of pleuritis, that 
it scarcely possesses any importance as a sign to be relied upon in the 
diagnosis prior to the occurrence of effusion. The latter takes place so 

' Vide Fournet, p. 210. 



246 PHYSICAL EXPLORATION OF THE CHEST. 

quickly after inflammation is established, that generally the pleural sur- 
faces are already separated before patients come under observation. 
In hospital practice this is almost uniformly the case. Instances, how- 
ever, are occasionally observed in which, notwithstanding a conside- 
rable, or even large accumulation of liquid in the pleural sac, a fric- 
tion-sound is apparent. Dr. Stokes was the first to report a case of 
this description, and others have been subsequently reported. The 
explanation of the presence of the sign under these circumstances is, the 
lung having become attached, not closely, but by means of bridles of 
false membrane, to the thoracic walls, the pleural surfaces continue to 
come into contact over a greater or less extent of surface. This may 
obtain anteriorly, while the whole posterior surface of the lung is sepa- 
rated from the walls of the chest by a large quantity of fluid ; and, 
under these circumstances, the physical signs posteriorly show the |] 
presence of liquid, whilst, anteriorly, a friction-sound may be ob- 
served. Of the instances in which a friction-sound occurs in pleu- 
ritis, in by far the larger proportion it appears in a later stage, 
after absorption. The pleural surfaces coming again into contact, 
are roughened by semi-organized lymph. This is so disposed in 
difi'erent cases as to give rise to simple rubbing, to a rougher quality 
of sound, distinguished as grating, or rasping, to creaking, or, occa- 
sionally, to a sound conveying the impression of a liquid. These 
diversities in the audible characters do not furnish any indications 
as to the quantity of exudation, or the gravity of the afi'ection, but 
simply denote difi'erences pertaining to the disposition of the mor- 
bid matter, together with variations of dryness and firmness, etc. ; and 
simple scarcely appreciable rubbing, may occur in cases in which the 
lymph is more abundant, and the disease more severe than in other 
cases in which the loudest, roughest sounds are discovered. The 
sounds are heard over the middle and lower portions of the chest in 
primary pleuritis, because, although the morbid condition may not be 
more marked here than at the summit of the chest, the respiratory 
opposing movements of ascent and descent are greater, especially 
in the male. The friction-sounds are not produced solely by the 
rubbing together of the pulmonic pleura and costal pleura, but pro- 
bably oftener and with greater intensity, by the contact of the dia- 
phragmatic pleura and costal pleura. The situation of the sign is 
sometimes, in fact, not over the lung, but over the diaphragm, viz., 
over the sixth and seventh cartilages.'^ But even after absorption a 
friction-sound is of rare occurrence in pleuritis. This is probably 

^ Sibson's Medical Anatomy. 



AUSCULTATION IN DISEASE. 247 

owing to the fact that adhesions of the pleural surfaces generally take 
place directly they are brought into contact. It is, however, not im- 
probable that the sound is discoverable at some points oftener than is 
supposed, because, inasmuch as the diagnosis of pleuritis is sufficiently 
established, in the large majority of cases, long before the period 
arrives when the physical conditions are favorable for the production 
of this sign, it is not always sought for with care over all parts of 
the chest. Occurring subsequent to absorption in the progress of 
III pleuritis, although not of importance as respects the diagnosis which 
it is to be presumed has been already made, it is yet of utility as 
j evidence that the surface of the lungs is in contact with the w'alls of 
II the chest. As stated by Fournet, in some cases this evidence is the 
|: more valuable, because, owing to the thickness of the layers of 
morbid deposit, percussion and the auscultation of the respiratory 
j sound may be insufficient to determine the fact that the liquid is ab- 
sorbed. At this period of the disease the sign is of good omen, 
denoting progress toward restoration. 

A friction-sound may accompany pleuritis developed as a compli- 
cation, or an intercurrent affection. In pleuro-pneumonitis it is occa- 
sionally observed, being due here to the pleuritic complication, and 
produced in the same manner as when the pleuritis is primary. It is 
also one of the signs which, inferentially, point to tuberculous disease. 
Occurring in connection with tuberculosis, it may originate in two 
ways : Firsts The deposit of small isolated tubercles beneath the 
pulmonary pleura, may occasion an irregularity of the surface suffi- 
cient to give rise to a strongly marked sound of attrition. Fournet 
gives an instance of this kind ; and a striking case was reported 
several years ago by Prof. Lawson.^ Second^ It is due to intercurrent 
pleuritis, confined to a circumscribed space, situated over the tubercu- 
lous deposits. Successive attacks of pleuritis, attended by the exu- 
dation of lymph, without liquid (dry pleurisy), and followed by 
adhesion of the pleural surfaces over the space affected, as is well- 
known, are so constant as almost to form a portion of the natural 
history of tuberculous disease of the lungs. A friction-sound, by no 
means uniformly, but occasionally, accompanies these attacks. Under 
these circumstances, the sign is confined to a small area at the sum- 
mit of the chest, and is of the grazing or rubbing variety, never 
presenting the rougher qualities of sound with this character, and 
thus situated, i, e. at the summit of the chest, it is indicative of cir- 

j * Western Lancet, Cincinnati, Oct. 1850. 

I 

I 



icel 



248 PHYSICAL EXPLORATIONS OF THZ C H Z 5 T. 

cmnscribed plenritis, wMcli is incidental to tubercle, and therefore iti^ 
becomes a phjeical sign of the latter disease. I: :? di^coTerable in 
only a small proportion of the cases of tuber: .; -^. _ ::? absence 
is not entitled to any weight as negative eTidei^ t : _ l - tl:. 
it is a si^n of considerable diagnostic importance, ueciiiiiiig 
connection it is of brief duration, usually continuing for a day or two 
only, being suspended by the adhesion of the surfaces oyer the spacej 
in which it was produced. And as this adhesion precludes the coi 
tinuance of moyements necessary for the production of the sound, ^ 
is not likely to occur, save at the first attack of plenritis. It is 
probable, but I am not aware of its having been clinically established,^ 
that a friction-sound indicative of tuberculous disease is more apt to 
he observed in females than in mal^ owing to the greater part which 
the superior costal type of respiration performs in their r^piratoij^ 
movements. 

Finally, a friction-sound is occasionally observed in certain stmo-' 
tural affections giTing rise to asperities or irregularities of the 
plem-al surfaces, such as cancers and tumors of different kinds. These 
affections are, however, very infrequent : and in its diagnostic relar 
tions to them the sign is of very little value. The sign here, and in 
all cases, merely indicates that the pleural surfaces are roughened.^ 
If, in connection with the sign, there are the symptoms, past or 
present, of intra-thoracic inflammation, and the sign be situated at | 
the middle or inferior portion of the chest, it iudicates, in forty-nine 
of fifty cases, plenritis, either primary or secondary. K it exist at 
the summit of the chest within a circumscribed space, and is asso-i 
ciated with symptoms leading to the suspicion of tuberculosis, it is ^ 
highly significant of that affection. And if it be found under drcum- 
stances iu which neither pleurisy nor tubercle are evidenced by asso- 
ciated signs and symptoms, it proceeds from emphysematous tumoi8| 
or other affections, the nature of which may not be determinable.^ 

The discovery of a pleural friction-sound as a physical sign, was 
made by M. Honore, a contemporary with the discoverer of auscul- 
tation.* He brought to Laennec a patient presenting the sound, to 
which the latter applied the title of the rubbing sound of ascent and 
descent {hruit de frottement ascendant et descendant). Laennec, 
however, as already stated, failed to perceive its connection with 

* Dr. Walsbe states that intra-thoiatae fnc^cm. is sranelimes smmJated by tihie more- 

ments of the scapnla in breathing. 

* "Vide Treatise on Mediate AnseullaticHi, ete^ by T^pottip*^ 



AUSCULTATION IN DISEASE. 249 

pleurisy, but attributed its production to interlobular empbysema. 
The merit of pointing out more fully its characters, and determining 
its true pathological significance, belongs to a French observer, M. 
Raynaud.^ 

PHENOMENA INCIDENT TO THE VOICE. 

With a previous knowledge of the vocal phenomena pertaining to 
different portions of the respiratory system in health, the abnormal 
modifications are readily apprehended. The more important of the 
vocal signs of disease consist of the characteristics of the normal 
bronchial and tracheal or laryngeal voice, transferred to situations 
where they are not found in a healthy condition. This class of 
signs will constitute one division of the morbid phenomena inci- 
dent to the voice, comprising exaggerated vocal resonance and 
hronchophony , Under this head are comprehended all abnormal 
modifications, in which the intensity of the normal vesicular vocal 
resonance is morbidly increased, or gives place to a sound not only 
more intense than belongs to health, but presenting other of the 
characters which pertain to the normal bronchial, tracheal, or laryn- 
geal voice. It sufiices for all practical purposes to include simply 
exaggerated resonance and bronchophony, in a single division ; and 
although, strictly speaking, there is an inaccuracy in applying the 
term bronchophony to a sound more intense than the normal bron- 
chial, and even the tracheal or laryngeal voice, it is admissible for 
the sake of convenience, and is sanctioned by conventional usage. It 
would be not less inaccurate to designate an intense vocal sound in 
any part of the chest, by the terms tracheophony or laryngophony, 
although identical in character to that observed on auscultating the 
larynx or trachea. The signification of the term bronchophony is 
extended by all writers to embrace sounds, the intensity of which 
equals and sometimes exceeds the tracheal and laryngeal voice. It 
is usual, also, to make a distinction between exaggerated vocal reso- 
nance and bronchophony, the former expression denoting simple 
increase of the vesicular resonance, and the latter in addition 
to intensity, alterations in other particulars of the vocal sound. 
The distinction, as will be seen, is a valid one, but I can see no prac- 
tical advantage in treating of them under distinct heads, and, there- 
fore, with a view to simplify the subject, I have included both in 
the same division. To distinguish the gradations of bronchophony, 

' Vide Earth and Roger. 



250 PHYSICAL EXPLORATION OF THE CHEST. 

the terms weak and strong, maj be employed. The expression, 
weak bronchopliony, denotes that the distinctive characters are but 
little or moderately marked ; and the bronchophony is said to be 
strong, when, in intensity and other features, it is considerably or 
extremely marked. To indicate different degrees of simply exagge- 
rated Yocal resonance, adjectives of quantity, such as little, moderate, 
much, great, etc., are sufficiently exact for all practical purposes. 

The normal vocal resonance may not only be increased to a greater 
or less extent, but on the contrary, diminished and suppressed. 
Morbid changes in this direction will constitute another division of 
vocal signs, which may be distinguished by the simple expressions 
diminished and suppreBsed vocal reso?iance. 

In treating of auscultation of the voice in health, it was seen that 
when the stethoscope is applied over the trachea or larynx, frequently 
articulate words are found to enter the ear, sometimes perfectly, and 
IQ other instances partially. This, which very rarely, if ever, occurs 
over the chest in health, is sometimes observed in disease, and con- 
stitutes a distinct physical sign, caiWed pectoriloquy. This will claim 
separate consideration, and constitutes the third of the divisions of 
abnormal vocal phenomena. 

A fourth vocal sign consists of a partial transmission of the voice, 
elevated in pitch, and tremulous ; which, after Laennec, is called, 
from its resemblance to the bleating of the goat, oegophony. 

Agreeably to the foregoing divisions, the phenomena incident to the 
voice in disease may be arranged under four heads : 1. Exaggerated 
resonance and bronchophony. 2. Diminished and suppressed vocal ., 
resonance. 3. Pectoriloquy.- 4. ^gophony. Of these four classes 
of signs, the two first are by far the most important in a practical 
point of view ; in other words, the objects to be attained by ausculta- 
tion of the voice with reference to diagnosis, chiefly relate to the 
increase or diminution of the normal vesicular vocal resonance. Now 
to determine, in individual cases, whether the normal vesicular vocal 
resonance be increased or diminished, it is necessary to know what 
is the normal amount of vocal resonance. It has been seen that this 
varies considerably in different persons, so that neither the amount 
proper to any single individual, nor the mean intensity of a series of 
examinations, will serve as a standard for comparison. Here, as in 
other instances, it is necessary to judge of an abnormal deviation by 
comparing one side of the chest with the other. But in instituting 
this comparison, an important consideration is to be taken into account. 



AUSCULTATION IN DISEASE. 251 

viz., it has been seen that in health, there does not exist perfect cor- 
respondence between the two sides of the chest as respects the degree 
of the normal vocal resonance. Happily the variations in the two 
11 sides are found to observe a certain rule, which must be borne in 
Ij mind, in order to avoid attributing to disease what may be due to a 
disparity entirely compatible with health. 



1. Exaggerated Vocal Resonance, and Bronchophony. — 
After the foregoing remarks, a brief description of the characters 
distinctive of these vocal signs will sufl&ce. With the ear applied to 
i certain parts of the healthy chest, for example, the infra-clavicular 
region, in front, or the infra-scapular, behind, the act of speaking 
generally occasions a certain diffused, dull resonance, the sound ap- 
pearing to come from a distance, and accompanied with a feeble 
vibration or thrill. This is the normal vesicular vocal resonance. 
Now this normal resonance may be rendered by disease more intense, 
in other characters than intensity remaining the same as in health. 
The vocal resonance is then simply exaggerated. The reverberation 
of the voice is abnormal, and there is usually more vibration or 
thrill felt by the ear ; but the sound is still distant, diffused, and 
dull. If, however, well marked bronchophony become developed, not 
only is the resonance usually greater, but the sound acquires a certain 
concentration and clearness ; the voice seems to be near the ear, while 
the accompanying vibration may or may not be proportionally great. 
The distinction, thus, between simply exaggerated resonance, and 
well-marked morbid bronchophony, is real, and the two signs may be 
clinically discriminated from each other without difficulty. It is not 
therefore strictly correct to say that they are essentially identical, 
the difference consisting only in the degree of intensity of the reso- 
nance. But it is true that both may proceed from similar physical 
and pathological conditions ; and that, in diagnosis, their significance 
is not materially different. Moreover, exaggerated resonance not 
infrequently merges into bronchophony, and, again, the latter, in the 
progress of the same disease, may give place to the former. Hence, 
it is not very essential, practically, to observe always with precision 
I the distinction ; and for this reason I do not give to each separate 
I consideration. The vibration or thrill, it is important to note, does 
I not always increase in a uniform ratio to the exaggeration of the 
resonance, the clearness and concentration of the sound, and the ap- 

I parent proximity to the ear, pertaining to the thoracic voice. In 

I 



252 PHYSICAL EXPLORATION OF THE CHEST. I 

strong bronclioplion J, the ear sometimes receives a shock or concussion, 
like that felt in auscultating the trachea or larynx, "which may even i 
be painfully intense. In other instances, the fremitus seems to be not i 
greater than belongs to health. The sound sometimes has a metallic, ' 
ringing tone. Occasionally it is somewhat tremulous. The latter is | 
peculiar to the aged. In degree, both exaggerated vocal resonance j 
and bronchophony present, in different cases of disease, great varia- , 
tions. The intensity of the thoracic voice may exceed that of the i 
normal laryngeal or tracheal. This is a fact not only interesting, but 
important in its bearing on the explanation of the mechanism by i 
whicb morbid bronchophony is produced. Anotber fact, also interest- 
ing, and in the same point of view important, is, the pitch of sound ! 
is not in all instances identical with that of the normal laryngeal or i 
tracheal voice. Both the foregoing facts are sufficiently attested by ' 
observations, but they are to be regarded in the light of exceptions to , 
the general rule. Finally, abnormal intensity of the thoracic voice | 
continues, certainly in the large majority of cases, constantly ; that is, it ; 
is always found on auscultation, so long as the pathological conditions 
of the lung to which it is incident continue ; in other words, it is not , 
an intermitting sign, like the bronchial rales, now present, and now i 
absent, but steadily presisting for a certain period, in this respect j 
resembling the crepitant rale and the bronchial respiration. This I 
last statement is in direct opposition to the opinion of Skoda, who main- 
tains that the alternate absence and presence of the thoracic voice is j 
a well-known and a common occurrence, and that bronchophony may ■ 
appear and disappear several times in the course of a few minutes.-^ ' 
The question is one to be settled purely by observation, and the i 
experience of others does not sustain Skoda's assertion. Intermit- j 
tency is an important point in the support of certain theoretical 
views entertained by Skoda, which will be briefly noticed presently ; i 
and this circumstance, it may be remarked, does not tend to enhance \ 
confidence in the accm-acy of the observations on which his opinion 
is professedly based, without inteij^ding by this remark to convey an i 
imputation of want of good faith. I 
The recognition of exaggerated vocal resonance and bronchophony, i 
practically, involves no difficulty. It is sufficiently easy to determine, \ 
on comparison of the two sides of the chest in corresponding situa- I 
tions, a disparity in the degree of resonance, and the several charac- 
ters pertaining to bronchophony. There is no liability of confound- 

^ Translation, by 3rarkham. Am. ed. page 68. 



AUSCULTATION IN DISEASE. 253 

ing these with other signs. The only error to be guarded against is, 
attributing to disease differences between the two sides which exist 
normally. Under the head of Auscultation in Health it has been seen 
that normal differences are observed in a large proportion, of persons. 
They observe, however, a regular law, viz., the greater relative in- 
tensity is on the right side ; and this is frequently found to be the 
case over all the regions on this side, but it is especially marked at 
the summit in front. Exaggerated vocal resonance may be said to 
exist naturally at the superior anterior portion of the right chest, in 
a large number of individuals, amounting, in some instances, to bron- 
chophony. From this fact it follows that the resonance on the right 
side must be considerably greater than that on the left, to warrant 
the inference that it proceeds from disease ; while a slightly greater 
resonance on the left than on the right side, is highly significant of 
a morbid condition. The coexistence of other signs incident to the 
same physical conditions, is a safeguard against the mistake of con- 
founding morbid with natural variations. 

The physical condition of which exaggerated vocal resonance and 
bronchophony are the signs, in the great majority of the cases of 
disease in which either is present, is increased density of the pulmo- 
nary structure. They occur in the different affections which give 
rise to the broncho-vesicular and the bronchial respiration, and are 
generally found in combination with these signs. Bronchophony is 
more uniformly present, and is most strongly marked, in connection 
with the solidification incident to the second stage of pneumonitis. 
In that disease, the situation in which it is observed is usually the 
middle and lower thirds of the posterior surface of the chest on one 
side, the seat of the inflammation, in the adult, being the inferior 
lobe, save in a small proportion of cases. It is in pneumonitis espe- 
cially that the bronchophony is strong or intense, the voice seeming 
to be very near the ear, attended by concussion or shock, the pitch 
sometimes notably higher than on the unaffected side, and the sound 
occasionally somewhat metallic in its tone. As respects the loudness 
of resonance, however, and the presence of the other characters, 
different cases of pneumonitis present great variations, dependent on 
differences in the degree of solidification, on more or less obstruction 
of the bronchial tubes, and other circumstances less obvious. The 
character of the voice, other things being equal, probably exerts an 
influence on the intensity of the sign ; but with reference to this 



'254: PHYSICAL EXPLORATION OF THE CHEST. 

point, different observers entertain discrepant opinions. Laennec, i 
Fournet, C. J. B. Williams, and Hughes, regard a treble voice as ^ 
faTorable for transmission tbroughout the chest, and, hence, broncho- i 
phony, other things being equal, is sti'onger in females and children i 
than in males. Barth and Roger, and Walshe, on the other hand, think ' i 
that a grave tone conduces to a greater development of the sign, and ! 
that it is most likely to be marked in males and adults. The strength j 
of the resonance will be proportionate to the power of the voice, irre*| ,^ 
spective of its pitch or special quality. These, and other circum- I 
stances, such as the thickness of the muscular and adipose layers ' 
covering the chest, affect, of course, the resonance in health as wellv ja 
as that incident to disease. The difference of opinion among dif- '% 
ferent observers just referred to, is perhaps due to their attention not i 
being directed to the same elements of those entering into the thoracic i 
voice. The reverberation and vibration are greater, coeteris paribus, in I 
persons whose voices are grave or bass ; but the force or extent witb* I 
which the voice penetrates the ear is probably greater when th^ j 
pitch of the oral voice is high. Bronchophony is not present in alM % 
cases of pneumonitis, and in some instances the vocal resonance is' : 
not even exaggerated, so that absence of either or both of these 
signs, by no means affords positive evidence against the existence <4w 
the disease. They are present, however, in a greater or less degree, 
in the great majority of instances. They may be present without 
being associated with bronchial respiration, and in such instances I 
they are highly important with reference to the question of solidifica^ 
tion. 

Next to pneumonitis, the affection in which exaggerated vocal 
resonance and bronchophony are most frequent in occurrence, and 
most important as physical signs, is phthisis. A tuberculous deposit 
gives rise to a resonance exaggerated, or to bronchophony, which is t 
strong in proportion to the quantity of tubercle, the degree of solidity 
which it induces, its extension to the superficies of the lung, and its 
proximity to the larger bronchial tubes. It is sufficiently intelligible 
that these circumstances will affect the amount of exaggeration, or the 
intensity of the bronchophony, in addition to the strength and cha- 
racter of the voice of the individual, etc. Owing to the diversity 
pertaining to the physical conditions favorable for the production of 
these signs, different cases of tuberculous disease differ greatly as 
respects theii' presence and their prominence. Even an exaggerated 
resonance may not be appreciable in some instances in which a con- 



! 



AUSCULTATION IN DISEASE. 255 

siderable quantity of tubercle exists. For example, if a tuberculous 
mass be separated, on the one hand, from the larger bronchial tubes, 
and, on the other hand, from the walls of the chest, by layers of 
healthy lung, the vocal resonance may scarcely, if at all, exceed a 
normal degree of intensity. It is probable, also, that accumulation 
of mucus or other morbid products in the bronchial tubes may occa- 
sion the temporary suspension of the thoracic voice. Its presence, 
therefore, as necessary to the diagnosis, is much less to be counted 
on even than in pneumonitis ; nor is the intensity with which it may 
be present to be considered as indicating the abundance of the deposit. 
Bronchophony is much oftener absent in phthisis than in pneumonitis, 
and it is very rarely so strongly marked in cases of the former, 
as it is in the larger proportion of the cases of the latter disease. 
Hence its value is less in phthisis. Occurring in connection with 
tuberculous disease, bronchophony and exaggerated resonance are 
almost invariably situated at the summit of the chest, in the infra- 
j clavicular, and scapular regions, oftener the former. They do not 
extend over so large a space as in cases of pneumonitis affecting 
either the lower or upper lobes, being usually limited to a cir- 
cumscribed area. These are distinctive features of the signs as inci- 
dent to tubercle ; but the history and symptoms, in conjunction with 
all the physical signs, rarely render it a difficult problem to decide 
between pneumonitis and tuberculosis. It is in the diagnosis of 
phthisis, especially, that the normal variations in vocal resonance at 
the summit of the chest are important to be borne in mind. Exag- 
gerated resonance on the right side, contrasted with the left, and 
even bronchophony, alone, are not evidence of the presence of the 
deposit of tubercle ; while a slight exaggeration on the left side, in 
itself, is sufficient ground for presumption that the deposit exists. 

Increased density of the lung, in consequence of compression by 
the accumulation of liquid within the pleural sac, may give rise to 
exaggerated vocal resonance and even bronchophony. Under these 
i circumstances the latter is very rarely marked, and frequently both 
are absent. So true is this, that in a case of pleurisy with effusion, 
strong bronchophony should occasion suspicion of solidification of 
lung from some cause, in addition to reduction of its volume by com- 
pression ; in other words, it would denote either coexisting tuberculosis 
or pneumonitis. Excepting some instances in which the lung is re- 
Itained in contact with the walls of the chest by adhesions, the effect 
■jof the accumulation of liquid is to remove it to the upper and poste- 



256 PHYSICAL EXPLORATION OP THE CHEST. 

rior part of the cliest. BronchophonY or exaggerated resonance, if 
either exists, will then be heard at the summit, in front or behind. It 
is sometimes limited to the site posteriorly of normal bronchophony, 
viz., over the tipper part of the interscapular space, but is, by no 
means, constantly present even in that situation. Over the portion 
of the chest corresponding to the space occupied by the liquid, the 
resonance is not exaggerated certainly in the vast majority of cases, 
and this is to be taken into account in determining the fact of pleu- 
ritic effusion ; Tvhile existing over the inferior part of the chest, it 
indicates the presence of solidified lung. 

Serous infiltration or oedema occasions increased density of the 
lung, and may give rise to exaggerated resonance. Marked broncho- 
phony, however, is very rarely, if ever, developed in this affection ; 
and both signs are frequently absent. 

In the rare forms of disease in which a portion of the lung 
is solidified by carcinomatous or melanotic deposits, extravasated 
blood, gangrene, the typhoid material, syphilitic induration, and also 
in cases of extra-pulmonic morbid growths, exaggerated resonance 
and bronchophony may or may not be present. The circumstances 
which should lead the diagnostician to attribute the presence of these 
signs to some one of these affections, instead of the more common 
morbid conditions to which they are incident, are the same that have 
been noticed in connection with the subject of bronchial respiration, 
to which the reader is referred. In general terms, if the exagge- 
rated resonance or bronchophony be circumscribed in extent, not 
confined to the summit, but situated in any part of the chest, and 
persisting (these circumstances excluding the diseases previously re- 
ferred to), we may infer the existence of some one of the affections 
just enumerated. In determining which one of these several affec- 
tions exists, in individual cases, we are to be guided by the circum- 
stances associated with the physical signs ; for example, the expec- 
toration of blood in pulmonary apoplexy, and of fetid matter in 
gangrene ; the pre-existence of typhoid disease, or syphilis, etc. 

It has been stated that, of the instances in which the signs under 
consideration occur, in the vast majority, the physical -condition is 
increased density of lung. As an exception to this rule, exaggerated 
resonance and even bronchophony have been sometimes observed in 
an affection characterized by abnormal rarefaction of lung, viz., 
emphysema. Their occurrence, however, is exceptional as regards the 



AUSCULTATION IN DISEASE. 257 

physical signs of that affection, — the rule being a degree of vocal 
resonance not exceeding, and frequently falling below that of health. 
To the fact of their occasional presence in a marked degree in em- 
physema — a fact not generally stated by writers on physical explo- 
j ration — Dr. Walshe has particularly called attention.^ 
ij Dilatation of the bronchial tubes is another morbid condition in 
I which exaggerated vocal resonance and bronchophony occur. In 
|! this rare lesion, the dilated bronchise are surrounded, to a greater or 
;j less extent, with condensed or indurated lung, so that it is difficult to 
;| say what is the relative proportion of the exaggerated resonance or 
j bronchophony, which is fairly attributable to the enlarged calibre of 
the tubes. Bronchophony is not constantly associated with the 
lesion, and is present in different instances with variable degrees of 
intensity, sometimes being very strongly marked, when the dilatation 
coexists with considerable induration of the surrounding lung. 

The mechanism of bronchophony, as of some other physical signs, 
offers scope for much theoretical discussion. In a practical point of 
view, it is not very important ; nor is uniformity of opinion in regard to 
it necessary to agreement in so much of the principles and practice of 
i auscultation as relates to the availability of the sign in the diagnosis of 
diseases. To this part of the subject, therefore, as in other instances, 
I shall devote but little space, referring the reader who may desire a 
more extended consideration of it, to works which professedly treat 
at length of the physical principles involved in the production of 
auscultatory phenomena. Laennec attributed the phenomena per- 
jtaining to the thoracic voice, to the greater conducting power of lung, 
when its density is increased. According to this explanation, the 
vibrations of the vocal chords, and of the air within the larynx, are 
propagated downward along the walls of the bronchial tubes, or the 
air contained in the tubes, or through the medium of both, and are 
heard in diseases attended by solidification of lung, with more inten- 
jsity than in health, simply because solidified lung is a better con- 
ductor of sound than air-vesicles filled with air. This explanation 
has generally been accepted as satisfactory, until recently it has been 
found there are certain difficulties which it does not fully meet, and 
|it has been attempted by Skoda to disprove altogether its correct- 
ness, and to substitute another theory, to which reference has been 
made in treating of bronchial respiration. The theory of Skoda 
attributes bronchophony, as well as the bronchial respiration, to the 

: * Op. cit. 

I 17 



'i 



258 PHYSICAL EXPLORATION OF THE CHEST. 



reproduction of sonorous vibrations within the bronchial tubes, m 
accordance with the musical principle of consonance. The bronchial 
tubes, according to him, take no direct part in the mechanism ; that 
is to say, he excludes vibration of the walls of the tubes from any 
participation in the resonance, regarding the column of air contained 
within the tubes as alone concerned in the production of the thoracic 
sound. In the normal condition of the lungs, the consonating sounds 
are slight, owing to the smaller bronchial tubes being membranous, and 
the want of firmness in the surrounding parenchyma ; but whenever 
the density of the lung is increased, provided the tubes remain 
pervious, the physical conditions necessary for stronger consonance 
are present ; and hence, bronchophony is developed^ under these 
circumstances. In support of this theory, it is assumed by Skoda 
that bronchophony is absent whenever the bronchial tubes are ob- 
structed, and that it appears and disappears frequently within a brief 
space of time, owing to the alternate removal and accumulation of 
mucous secretions. This, to the extent asserted by Skoda, is at 
variance with common observation. That obstruction, especially of 
the larger tubes, may occasion a suspension of the sign, and affect its 
intensity, is probably true ; but it is certainly not so dependent on 
the presence or absence of mucous secretions in the smaller subdivi- 
sions of the bronchise, as Skoda assumes. Its constancy in cases 
characterized by cough and abundant expectoration is incompatible 
with that position. This consideration alone renders the theory of 
consonance inadequate, in itself, to account for the phenomena of 
bronchophony. In disproval of Laennec's doctrine of conduction, 
Skoda declares, as the result of experiments on hepatized lung re- 
moved from the body, that the conducting power is less than that of 
healthy lung ; and that, hence, if exaggerated resonance depended on 
conduction alone, it should exist in health rather than when the pul- 
monary structure is solidified by disease. The experiments on which 
this opinion is based, consist in listening with the stethoscope applied 
over a portion of solidified lung, while another person speaks through 
a stethoscope applied over parts of the same lung, more or less dis- 
tant. It is obvious that such experiments do not fairly represent 
the circumstances under which bronchophony takes place in the living 
body, unless it be gratuitously assumed (as it is by Skoda), that the 

' The same explanation of bronchophony was offered many years ago by Dr. E. A. 
Carr, in a paper read to a medical society, but not published. Vide, Buffalo Medical 
Journal, vol. viii. 1853. 



1 



AUSCULTATION IN DISEASE. 259 

, column of air in the broncliial tubes is the only agent concerned in 
the mechanism. Even with this assumption, the cases are hardly 
parallel. But, as already remarked in connection with bronchial 
respiration, others, in repeating the same experiments, do not arrive 
at the same conclusion. Dr. Walshe has found that different speci- 
mens of hepatized lung do not conduct sound equally, a fact ac- 
cording with the variations in the intensity of vocal resonance, 
which are clinically observed in different cases of pneumonitis, but 
that in some instances, the sound is conducted with great intensity. 

ii Again, as stated by Walshe, if a person speak through a stethoscope 

I introduced into the trachea of a subject dead with pneumonitis, in a 
case in which bronchophony had been marked during life, and another 
person listen to the chest, there is often nearly complete absence of 
sound. Here are the physical conditions for consonance, provided 
the bronchial tubes are unobstructed. Skoda endeavors to explain 
the non-production of sound in this experiment, by assuming that, 
after death, the smaller tubes are always filled with fluid ; but, accord- 
ing to Walshe, close examination showed this not to have been the case 
in some of the subjects on which the experiment was made. But 

I there are other and more positive considerations, which render the 
theory of consonance untenable. A consonating sound always sus- 
tains a fixed harmonic relation to the original sound upon which it 
depends. The two sounds must be in unison. Now it is a matter of 

I observation that the sound heard over the chest, and that heard over 
the larynx of the same patient, are not always in harmonic relation 
to each other : in other words, musically speaking, they are discords. 
Again, air contained within a certain space is capable of being thrown 
into consonating vibrations, only with certain notes which correspond 
to, or are in unison with the fundamental note of the space. But 
bronchophony is produced by speaking in various tones ; some of 
which must be at variance with the fundamental note of the space in 
which the consonating vibrations are imagined to take place. Finally, 
a consonating sound, except under conditions which the pulmonary 
organs cannot furnish, is always very much more feeble than the 

i original sound ; yet, the thoracic voice is sometimes more intense 
than over the trachea or larynx. The theory of consonance, there- 

i fore, is at variance with the laws of acoustics.^ 

The doctrine of Laennec, which, as has just been seen, is by no 

' The author would express his indebtedness for the foregoing points, to the admi- 
rable work of Dr. Walshe (edition for 1854) ; to which also he would refer the reader 
desirous of a fuller consideration of the subject. 



260 PHYSICAL EXPLORATION OF THE CHEST. 

means disproTed, nevertheless fails to account for all tlie phenomena 
of bronchophony. As already remarked, the thoracic voice has been 
observed to be intense, when the lung, instead of being condensed, is 
actually rarefied, viz., in emphysema. Moreover, simple conduction 
is inadequate to explain the intensification of sound which, although 
infrequent, does occasionally take place within the pulmonary organs ; 
and it is equally inadequate to explain the variation of pitch some- 
times observed between the laryngeal and the thoracic voice. The vocal 
sounds must be, in certain instances, at least, in some way reinforced 
within the bronchial tubes, and also receive there modifications of its 
quality and tone. Consonance may be one of the subsidiary agencies 
involved. In addition to this, and to the influences which the sound 
receives in passing by conduction through difi'erent media, reflection 
and reverberation probably take place, constituting what is distin- 
guished as union-resonance and echo. From some of the examples, 
employed by Skoda to illustrate his theory of consonance, it would 
seem that under this title he intended to comprehend the acoustic 
principles referred to by the terms just mentioned.^ With the fore- 
going brief discussion, which, in view of the practical objects of this 
work, has been perhaps already too extended, I leave the considera- 
tion of the mechanism of bronchophony, repeating the remark, that 
the subject is one chiefly of speculative interest ; for, whether the 
theory of consonance be received or rejected, is a matter unimportant 
so far as the significance and value of the sign are concerned, our 
knowledge of the latter being based solely on clinical and autopsical 
observations. 

An incidental phenomenon which was noticed in treating of healthy 
vocal resonance, is of interest and importance in connection with 
bronchophony as a sign of disease. I refer to a souffle or blowing 
sound accompanying words spoken aloud, but which is apt to be 
obscured by the resonance and vibration, and is therefore more satis- 
factorily observed when words are whispered. In cases of pneumo- 
nitis or tuberculosis, if the naked ear or stethoscope be applied over 
the solidified limg, the other ear being closed (a precaution always 
to be employed in auscultating for vocal resonance), and the patient 
requested to count in distinct and tolerably loud whispers, a bellows 
soimd, more or less loud, will be found to accompany each enunciated 
numeral. On comparing the result of the same procedure on the 

* For a full exposition of the principles of conduction, union-resonance, and echo, so 
far as they relate to this subject, the reader is referred to the treatise bv Dr. Walsbe. 



I 



AUSCULTATION IN DISEASE. 261 

healthy side in a corresponding situation, a sound in the latter in- 
stance will either be entirely wanting, or it will be notably more 
feeble, and also lower in pitch. A relatively intense and high-pitched 
souffle^ accompanying the act of whispering, is thus a physical sign 
having the same significance as bronchophony, and the bronchial 
respiration. In the character of the sound it is analogous to the 
latter. This sign is not only worthy of attention, as co-operating 
with bronchophony and bronchial respiration, and thus serving to 
confirm their validity, but it may be strongly marked in some instances 
in which the other signs just mentioned are imperfectly developed. 
In the latter point of view, it deserves more consideration than it 
has received from writers on physical exploration. 

In conclusion, the phenomena which have been presented under 
the head of exaggerated vocal resonance and bronchophony, taking 
into consideration, in individual cases, the situation in which they are 
observed, the space over which they are found to extend, their inten- 
sity, and their conjunction with other physical signs together with 
symptoms, are often of considerable value in diagnosis. 



2. Diminished and Suppressed Vocal Resonance. — The effect 
of certain morbid conditions is to diminish or suppress the normal 
vocal resonance. If, therefore, it be apparent that the resonance 
proper to any part of the chest in health is lessened or absent, evi- 
dence is thereby afibrded of the existence of some one of the morbid 
conditions which are known to produce this effect. There being no 
fixed standard of normal vocal resonance, its diminution, as well as 
its increase, is determined by a comparison of the two sides of the 
chest. In the one case, not less than in the other, it is important to 
take cognizance of the normal disparity existing between the two 
sides in a large number of individuals, and also of the fact that the 
' relatively greater degree of resonance is naturally on the right side. 
Without due regard to the latter fact, the less amount of resonance 
on the left side so frequently found in health, might be attributed to 
disease situated in that side, as well as vice versa. An abnormal dis- 
parity between the two sides, provided the greater resonance on one 
side do not exceed an amount compatible with health, may proceed 
from a morbid diminution on one side, or from a morbid exaggera- 
tion on the other side. In the one case, the disease is seated in the 
^ side in which the resonance is relatively less ; in the other case, the 
affected side is that on which the resonance is relatively greater. 



i 



262 PHYSICAL EXPLORATION OF THE CHEST. 

Without the co-operation of other signs, or of symptoms, it would 
sometimes be difficult to determine, under these circumstances, to 
which side the disease is to be referred ; but with the information to 
be derived from other sources, there can hardly be much room for 
doubt on this score in any instance. 

The morbid conditions to which diminished vocal resonance is in- 
cident are emphysema, certain cases of solidification, obstruction of 
one of the large bronchi, the presence of abundant liquid effusion, 
and of air in the pleural sac. Of these several conditions, in the two 
first, viz., emphysema and solidification, the normal resonance is 
diminished, not uniformly, but in a certain proportion of cases only. 
In emphysema, diminution is the rule, but in some exceptional instances 
the resonance is notably increased. In solidification, the resonance 
is generally increased. It is in connection with this condition, as 
has been seen, that exaggerated vocal resonance and bronchophony 
occur in the great majority of instances. As exceptions to the gene- 
ral rule, however, an opposite effect is sometimes induced. Cavities 
filled with liquid products also occasion a notable diminution of reso- 
nance within a circumscribed space corresponding to the side of the 
excavation. Obstruction of one of the large bronchi diminishes the 
resonance in so far as the column of air within the bronchial tubes 
takes part in the propagation of vocal sounds, and, perhaps, also, in 
consequence of the changes induced in the lung in which the circula- 
tion of air is cut off. In pleuritis, hydrothorax, and pneumo-hydro- 
thorax, the diminution of resonance is the rule, and in these affections 
suppression is often observed. The presence of liquid in the two 
former affections, and of air together with liquid in the one last men- 
tioned, remove the lung so far from the thoracic walls that the vocal 
vibrations emanating from the larynx, as well as the respiratory 
sounds, fail to reach the ear of the auscultator ; or, if appreciated, 
are feeble and distant. Absence of vocal resonance, or abnormal 
diminution, are to be embraced among the signs by which the presence 
of liquid, or of liquid and air, is to be determined. It is chiefly in 
this application that the sign possesses clinical value ; and inasmuch as 
the diagnosis of these affections is usually not attended with difficulty, 
diminution and suppression of vocal resonance are to be ranked 
among the signs of minor importance. Nevertheless, in accumulating 
evidence in order to arrive at a conclusion with the utmost positive- 
ness, a feeble and distant vocal sound on the affected side, or the 
absence of resonance, is a point entitled to weight, and should not 
be overlooked. 



AUSCULTATION IN DISEASE. 263 

3. Pectoriloquy — Cavernous and Amphoric Voice. — The dis- 
tinctive characteristic of pectoriloquy, as the name imports, is the 
transmission, not simply of vocal sound, but speech : the articulate 
words are appreciated by the ear applied to the chest. This cha- 
racteristic is sufficient to distinguish it from bronchophony, but, as 
will be presently seen, there is not niuch practical advantage in re- 
garding it as a distinct physical sign ; and at the present time some 
writers treat of it as a modified form or variety of bronchophony.^ 
It is accompanied by bronchophony in a certain proportion of cases, 
but not invariably. The type of pectoriloquy is to be found among 
the phenomena incident to the voice in health. With the stetho- 
scope placed over the trachea or larynx, the ear, in a small propor- 
tion of instances, receives with distinctness the words enunciated 
by the person examined. In most instances the articulated voice is 
not perfectly transmitted through the instrument, but heard with 
more or less indistinctness. The nature of the sign, and its different 
degrees of completeness, may thus easily be made familiar practi- 
cally, by auscultating the trachea and larynx of different individuals. 
This phenomenon does not pertain normally to any portion of the 
chest, but it may be presented in connection with certain morbid 
conditions, and then constitutes true pectoriloquy, or chest-talking. 
The intensity with which the words enter the ear may even be greater 
than when the stethoscope is applied over the larynx or trachea. 

Laennec regarded pectoriloquy as a pathognomonic sign of a pul- 
monary cavity. He divided it into three varieties, viz., perfect, im- 
perfect, and doubtful. In perfect pectoriloquy the transmission of 
the articulated voice is complete ; in the imperfect variety, the words 
are indistinctly heard ; and when doubtful, it is not distinguishable 
from bronchophony, save by circumstances other than those pertain- 
ing to the voice. It is evident that in giving to pectoriloquy this 
comprehensive scope, as regards its audible characters, together with 
so limited an application in its diagnostic significance, Laennec was 
influenced by the desire manifested in other instances to establish for 
( each particular lesion a special physical sign. Taking his own de- 
scription of doubtful and incomplete pectoriloquy, these varieties are 
neither more nor less than bronchophony. So far as distinctive 
characters are concerned, Laennec did not attempt to draw the line 
of demarcation. According to him, bronchophony is, in fact, pecto- 
riloquy, whenever, from its situation, the general symptoms, and the 

* Walshe, Skoda. 



264 PHYSICAL EXPLORATION OF THE CHEST. 

progress of the disease, it may be deemed to proceed from a cavity.* 
Observations since the time of Laennec have abundantly disproved 
the hypothesis of the transmission of speech, even ^yhen most com- 
plete, being always due to the presence of a cavity ; and, at the pre- 
sent time, pectoriloquy, be it ever so perfect, has not the significance 
which it possessed in the estimation of the illustrious founder of aus- 
cultation. 

The physical condition, irrespective of excavation, to which pecto- 
riloquy is sometimes incident, is solidification of lung, either from 
inflammatory or tuberculous deposit. Exaggerated vocal resonance, 
to a greater or less extent, coexists. Under these circumstances the 
sign is, in fact, incidental to bronchophony. The other signs indica- 
tive of solidification will be associated with it, viz., notable dulness 
on percussion, and the bronchial respiration. In both forms of dis- 
ease, but more especially in pneumonitis, the pectoriloquy will be 
diffused, i. e. heard over a considerable space. In connection with 
crude tubercle, the situation in which it is found is at the summit of 
the chest ; and it is most apt to occur in pneumonitis affecting the 
upper lobe. It is by no means frequently present in the affections 
just mentioned, but only in a small proportion of cases, dependent, 
it is probable, on a continuous and uniform density of lung between 
some of the larger bronchial divisions and the thoracic walls. 

Cavernous pectoriloquy, however, does occur ; that is to say, the 
sign may proceed from an excavation. But it is perhaps as rarely 
observed in connection with cavities, as in cases in which the lung 
is solidified. Tuberculous excavations are sufficiently common, yet 
it is seldom that well-marked pectoriloquy is developed in the pro- 
gress of phthisis. Its occurrence cannot therefore be counted on as 
evidence that the disease has advanced to the stage of excavation. 
Occurring at a late period, when it is altogether probable, from our 
knowledge of the pathological history of phthisis, that a cavity, or 
cavities, have formed, how are we to determine that it is not caused 
by the solidification from the presence of crude tubercle, which fre- 
quently exists in the vicinity of the excavations ? The circumstances 
on which this discrimination is to be based are not so much any 
peculiarities of character, as its intermittence when due to a cavity ; 
its being limited to a circumscribed space, and associated with other 
physical signs indicative of excavation, viz., tympanitic resonance on 

^ Vide Treatise on Diseases of the Cliest, etc. Translated by Forbes, page 39, New- 
York edition, 1830. 



AUSCULTATION IN DISEASE. 265, 

percussion, with, in some instances, the hruit de pot fele, and the 
cavernous respiration, alternating with gurgling rales. If these cir- 
cumstances were not conjoined, in many if not in most instances it 
would not be easy to determine whether the pectoriloquy be or be not 
cavernous. The point, happily, is one of clinical curiosity, rather 
than of much practical importance. Cavernous pectoriloquy requires 
the conjunction of several conditions. The cavity must be of consi- 
derable size. It must communicate freely with the bronchial tubes. 
It must be free, or nearly so, of liquid. It must be situated near the 
walls of the chest, and the sign is more likely to be produced if 
adhesion of the pleural surfaces have taken place over the part of the 
lung in which it is situated, so that, in addition to the thoracic walls, 
a thin condensed stratum of pulmonary structure alone intervenes 
between the exterior of the cavity and the ear of the auscultator. 
The walls of the cavity must be sufficiently firm not to collapse when 
it is empty. The space within the excavation must not be intersected 
by parenchymatous bands. The infrequency with which these seve- 
ral conditions are united, accounts for the absence of the sign, as a 
general rule, even when cavities exist, and for its being transient or 
intermittent in cases in which it may be sometimes discovered. 

In by far the greater proportion of the instancers in which cavern- 
ous pectoriloquy occurs, the excavations are due to tuberculous dis- 
ease. It may, however, be incidental to the cavities resulting from 
circumscribed gangrene and abscess. But, in addition to the great 
infrequency of the latter affections, the favorable conditions are less 
likely to be combined than in tuberculous excavations. It may also 
occur in some cases of perforation of the lung, establishing a commu- 
nication between the bronchise and the pleural cavity, giving rise to 
pneumo-hydrothorax. In that rare lesion in which a pulmonary 
cavity is simulated, or rather virtually exists, viz., pouch-like dilata- 
tion of the bronchise, pectoriloquy may be strongly marked. 

The voice resounding in a cavity of considerable size, sometimes 
assumes a musical intonation, resembling the modification which the 
vocal sound receives on speaking into an empty vase or pitcher. 
This constitutes what is called, from the similitude just mentioned, 
amphoric voice. The character is analogous to that belonging to the 
respiratory sound to which the same title is applied. It has no 
special significance beyond denoting the existence of a cavity, but, 
inasmuch as when it is strongly marked, it probably proceeds from an 
empty space, while ordinary pectoriloquy may be due to solidifica- 



tion, it has a positive diagnostic value in the rare instances in which 
it is heard- It occurs not only in pulmonarj excavations, but in 
eases of pneumo-h jdrothorax, with a fistulous conununicaidon between 
the bronchial tubes and the pleural sac. The characteristic sound is 
not nece^arilj accompanied bj the transmission of speech. An 
amphoric voice, therefore, may with propriety be regarded as a sign 
distinct from pectoriloquy. It is so regarded and treated of under a 
separate head by some writers.' Itsuffices, however, for all practical 
purposes to ii::::r :: :Jii5 ii.;: Iriitally and briefly iq the present 
connection. 

Pectoriloquy does i. : : : : : :. : r_ - : : r ?t-3nt relation to the intensity 
of thoracic resonance c: . : t : : ::/. zor is it dependent on 

the loudness of the or:/- : t , _ _ t r _ _: 7 e distinctly trans- 
mitted without being &-.-'. : t ~ n 1.0. combined in weU- 
marked bronchophony. _ _^ 1: is nnable to speak 
except feebly, or only ::. ~ : t.^ ; l ._t :: 7= the words ema- 
nating from the chest z t 7- ri : T T- ."ler and more 
distinct than when re 7 : : : t 1: Zl^ : :ismission of 
whispered words is dis:: _ : . .^y, which is 
regarded by Walshe Ti : _ > : : i- My own ob- 
servations lead me to a . 7 : _ , I „ t 17^7 i tedly fomid 
well-marked whisperinr iloquy over solidified lung ; and, with- 
out having analyzed c : : ~ _ irspect to this point, I should say 
that it is oftener mer '^i:! :_ - the transmission of words spoken 
aloud. This accords with the results obtained by auscultation of the 
voice in health, viz., whispered words are oftener transmitted over the 
trachea, larynx, and bronchi ; and in a single instance, imperfect 
whispering pectoriloquy was observed in the infra-clayiciilar region, 
while in no instance were words spoken aloud even partially trans- 
mitted. 

The mechanism of pectoriloquy claims but a few words, inasmuch 
as the physical principles involved are probably essentially identical 
with those concerned in the production of bronchophony. Conducted 
by the air contained within the bronchial tubes and cavity, aided by 
the bronchial waDs and solidified parenchyma^ when the intensity of 
the transmitted speech is considerable, the sound is probably rein- 
forced by reflection from the walls of the excavation, and possibly, 
also, to some extent^ by consonance, according to the theory of Skoda. 

' Bai& and JBog^; * Tide Aresmliarioo of the Voice in HeaWi, page 168. 



AUSCULTATION IN DISEASE. 267 

The amphoric modification of the vocal resonance is probably due 
to reverberation of sound within the cavity giving rise to a kind of 
echo. Skoda entertains the opinion that the development of the 
amphoric voice does not require a free communication between the 
cavity and the bronchial tubes, but that the necessary sonorous vibra- 
tions may be excited within the former, provided a thin layer of 
tissue only intervenes. Barth and Roger concur in this opinion. 

Pectoriloquy is an interesting physical sign, from the fact that it 
was the first observed by Laennec, and led to the application of 
auscultation to the investigation of pulmonary diseases. As respects 
its value in diagnosis, since it has been ascertained to accompany 
bronchophony in a certain proportion of cases of solidification, and to 
occur very infrequently in connection with cavities, it cannot be con- 
sidered to possess much practical importance. Barth and Roger 
propose to dispense with the use of the term pectoriloquy, and under 
the title of cavernous voice to include only the instances in which 
speech is transmitted from cavities. But so far as the sign alone is 
concerned, it cannot be determined whether it proceed from a cavity 
or not. This point is to be settled, not by the evidence received 
through the sense of hearing, but by reasoning on the circumstances 
with which the sign is associated. In other words a cavernous 
voice, exclusive of the amphoric voice, does not exist as a distinct 
physical sign. The distinction is consequently arbitrary. The reality 
of pectoriloquy, that is, the transmission of speech, as distinct from 
bronchophony, even when the two are associated, as is frequently but 
not invariably the case, is unquestionable. Its distinctive character 
is very clearly defined. It has therefore just claims to be recognized 
as an individual physical sign, although, as has been seen, it repre- 
sents anatomical conditions precisely opposite in character. Its 
pathological significance is always to be determined by the part of 
the chest in which it is situated ; the extent of surface over which it 
is heard ; its constancy or persistency ; and the other physical signs 
together with the symptoms which accompany it. 

4. ^GOPHONY. — The modification of the thoracic voice thus en- 
titled, has given rise to much discussion respecting its pathological 
significance, as well as its mechanism. Limiting the attention almost 
exclusively to the former of these two aspects of the subject, I shall 
not devote to it extended consideration, especially, as will be admitted 
by all practical auscultators at the present time, clinically, the sign 



268 PHYSICAL EXPLORATION OF THE CHEST. 

is among the least important of those furnislied by physical explora- 
tion. The characters by which it is distinguished are well defined 
and distinctive. Its peculiarities are sufficient to establish its indi- 
viduality; and, when well marked, it is readily recognized. The 
inferior rank which it holds, results from the infrequency of its oc- 
currence ; its superfluousness in certain of the instances in which it is 
observed, owing to the adequateness of other signs to the diagnosis ; 
and, according to the opinion ,of some, the uncertainty which attaches 
to it as an expression of a particular pathological condition. 

The essential features which characterize aegophony are, a peculiar 
tremulousness of the vocal sound, the pitch being elevated above that 
of the oral or laryngeal voice. With these characters it frequently 
bears a striking resemblance to the bleating cry of the goat, and this 
similarity is expressed in the etymology of the word segophony, which 
was employed to designate the sign by Laennec. In its audible 
character, however, it is by no means always uniform. In some in- 
stances a sound is produced which was compared by Laennec to that 
of the voice transmitted through a metallic speaking-trumpet. 
Another variety he likens to the peculiar tone of Punch in the puppet- 
show, produced by speaking in a high key, with the nostrils closed. 
Hence it is styled by the French, voix de poliehineUe. The force of 
the last illustration will be less generally appreciated in this country 
than in France, performances of Punchinello being as rare in the 
former, as they are common in the latter. A third variety the same 
author compares to the sound produced when a person attempts to 
speak with a solid substance between the teeth and lips. It is suffi- 
cient to say that the vocal resonance becomes segophonic whenever 
the sound is interrupted or tremulous, and the pitch more or less 
acute ; and that these distinctive traits may be presented in various 
degrees and proportions from strongly marked, pure segophony, down 
to the slightest modification in these particulars. The two elements 
which thus enter into the composition of the ^ophonic voice may 
not be present in an equal ratio. The sound resulting from their 
combination is by no means uniform. It may be feeble or strong. It 
may be so faint as to be scarcely appreciable, or the sign may be asso- 
ciated with exaggerated vocal resonance or even bronchophony. It may 
exist in every degree as respects intensity. The tremulousness may 
be strikingly marked, or just perceptible, with every intermediate 
shade. The pitch may be slightly or considerably raised. The 
bleating, vibrating intonation, accompanies the vocal resonance, but 



AUSCULTATION IN DISEASE. 269 

the two do not always occur synchronously. The former sometimes 
succeeds the latter, so that they may be perceived to be distinctly 
although slightly separated. The segophonic sound, as each word or 
syllable is pronounced, follows the articulation like an echo. The 
impression of distance is another feature belonging to asgophony ; the 
sound appears to be somewhat removed, and not produced directly 
beneath' the ear of the auscultator. 

In addition to the foregoing points pertaining to the audible 
characters, other distinctive traits relate to the situation where it is 
usually heard, the extent of its diffusion, etc. ^gophony does not 
occur indifferently at any part of the thorax. It is found much 
oftener than elsewhere at or near the inferior angle of the scapula; 
frequently being limited to a small space, and usually more marked 
at that situation, when it is more or less diffused. From the point 
just mentioned, when it is not thus limited, it generally extends, 
according to Laennec, and other observers, to the interscapular 
space, and in a zone from one to three fingers broad, following the 
line of the ribs toward the nipple. This rule as respects situation is 
not without exceptions. Fournet states, as the result of numerous 
observations, that it may exist over the greater part of the lateral 
and posterior portions of the chest, but never extending to the sum- 
mit. It has, however, been observed in the infra-clavicular region, 
and also diffused over nearly the entire chest on one side. It is 
sometimes found to shift its seat, or to disappear when the position of 
the patient is changed. The explanation of these facts involves a re- 
ference to the physical conditions upon which the sign is dependent, 
and will be noticed presently. Its duration is variable, but rarely 
extending beyond a brief period. The average time of its continu- 
ance is estimated from five to eight days ;^ but in a case of chronic 
pleurisy cited by Laennec, it lasted for several months. In the pro- 
gress of the same disease, viz., pleurisy, it may appear, continue only 
for a short time, and at a subsequent stage reappear for a brief period. 
This has been repeatedly observed, but is by no means an invariable 
rule. During the period of its continuance it is pretty constant, ^. e. 
heard at nearly every examination ; but it is not equally manifested 
with each act of the voice, or articulated word. It is more intense 
at some moments than at others, and may be temporarily suspended 
by an accumulation of mucus in the bronchial tubes, being reproduced 
immediately after coughing and expectoration. 

* Barth and Roger. 



270 PHYSICAL EXPLORATIOX OF THE CHEST. 

Laennec regarded ^gophony as conclusive evidence of the presencl^ 
of a certain quantity of liquid within the pleural sac. He asserts' 
that he discovered it in nearly every case of pleurisy that came* 
under his notice dui'ing the period of five years. Subsequent obser- 
vations have abundantly confii-med the fact of its occurrence in con-' 
nection with the pathological condition just mentioned, but in a pro- 1- 
portion of instances much less than was supposed by the founder of ^ 
auscultation. With the utmost veneration of the memory of Laennec, ''- 
it must be presumed that, with reference to segophony, as in the case 
of pectoriloquy, a strong desu-e to invest each sign with a special ' 
significance, representing constantly the same anatomical condition, 
to some extent afiected, unconsciously, the accuracy of his observa- 
tions. This presumption is strengthened by his confession of the 
difficulty, frequently, of discriminating gegophony from bronchophony 
and pectoriloquy ; and, also, by the importance which he attaches to 
pressing the ear very lightly against the stethoscope in seeking for 
this sign. This method of auscultating, suffices often to give to the 
voice an segophonic intonation. At all events, it is certain that 
well-marked aggophony, so far from being constantly or generally 
present in pleurisy, is one of the rarest of the physical signs, and 
there are doubtless many who have had considerable experience in 
physical exploration, without ever having met with a single good 
example of it. It may be associated with the presence of liquid of 
any kind between the plem-al surfaces, serum, pus, or possibly even 
blood; and it is therefore a sign which may be incident to ordinary 
plem'isy, the hemorrhagicvariety of the disease, empyema, pneumonitis 
with liquid eff'usion, and hydrothorax. Even in the time of Laennec, 
the uniform dependence of aegophony on the presence of liquid, was 
doubted by some observers, who professed to have discovered it in 
cases of simple pneumonitis, involving solidification of lung without 
liquid efi"usion. Skoda rejects entirely the special significance at- 
tached to it by Laennec, and declares that he has met with it both 
in simple pneumonitis, and tubercular infiltration. Such instances, if 
they exist, are certainly exceptional. "Without denying their occur- 
rence, it may be suspected that the presence of a small quantity of 
liquid, sufficient to occasion this sign, but not abundant enough to 
give rise to other physical evidences of efiusion, may be the explana- 
tion in some cases.-' The sharp tremulous character of the oral voice 

^ Normal agophony, due to the character of the oral voice in the aged, will be likely 
to be present on both sides of the chest. This will serve to distinguish it from the 



AUSCULTATION IN DISEASE. 271 

may, also, account for its occasional apparent manifestation. Bron- 
chophony, and the normal thoracic voice, assume frequently an gego- 
phonic character in the aged of both sexes, but especially in females. 
Moreover, with reference to this point, a distinction is to be made 
between distinctly marked segophony, and a slightly segophonic cha- 
racter of the thoracic voice. The latter may occur as a normal 
peculiarity, or in connection with solidification of lung, without in- 
vahdating the significance which properly belongs to the former. 
I But whether or not well-marked aegophony be sometimes incident to 
I solidification of lung alone, this fact must be admitted, viz., of the 
instances in which it is observed, in all save a few exceptional cases, 
it is due to liquid efi'usion. Observations also have sufficiently esta- 
blished that, in general, it demands for its production a small or 
moderate amount of liquid efi'usion. Laennec states that he had 
discovered it in cases in which there did not exist above three or four 
ounces of fluid in the chest. A quantity sufficient to produce slight 
compression of the lung, interposing a thin stratum between the 
pulmonary surface of the thoracic parietes, appears to furnish the 
necessary physical conditions. In the progress of pleurisy, the sign, 
when it occurs, is found at an early period of the disease. Laennec 
discovered it, in some instances, within a few hours after the attack, 
but generally not strongly marked until the second or third day. 
Where the quantity of efi'usion increases so as to produce consider- 
able compression of the lung, removing it at a distance from the 
greater part of the thoracic walls, the sign almost invariably disap- 
pears. It continues, therefore, frequently but a short time, perhaps 
for a few hours only, rarely longer than two or three days. Its limi- 
tation to a particular juncture in the course of the disease, and its 
short duration, undoubtedly are reasons why it is not discovered in 
many cases in which it exists. In some instances it may have 
occurred and disappeared prior to patients coming under observation. 
At a subsequent stage of pleurisy, when the quantity of liquid is 
reduced by absorption to that involving the requisite physical condi- 
tions, it is sometimes observed a second time, or it may be discovered 
under these circumstances, when it had not been observed pre- 
viously. Keturning segophony [egophonie de retour, cegopJionia 
redux), thus furnishes evidence of the progress of the disease toward 

morbid sign which, excepting some rare instances of hydrothorax, is limited to one side. 
But the character of the oral voice will be apparent. Moreover, the other physical 
signs of pleuritic effusion will be wanting. 



272 PHYSICAL EXPLORATION OF THE CHEST. 

restoration. The dependence of the sign on the presence of a cer- \ 
tain quantity of liquid, has been demonstrated by its appearance in j 
cases of empyema, in which paracentesis was resorted to, the aego- i 
phony, which had not existed prior to the operation in consequence \ 
of the large quantity of liquid, becoming developed after a portion i 
had escaped. It has been observed, during the removal of the liquid, 
to change its place as the quantity lessened, falling lower and lower 
on the surface of the chest, and finally disappearing after the whole 
of the fluid contents of the chest had been withdrawn.^ The fact of 
segophony being commonly found at a particular situation, viz., at 
the lower angle of the scapula, and over a narrow space extending 
from this point in the direction of the ribs to the nipple (the patient 
being examined in a sitting posture), has led to the supposition that 
the peculiar modification of the vocal sound is produced at the level 
of the liquid ; in other words, that the zone just mentioned indicates 
the height on the chest to which the efi"usion rises. It is not, how- 
ever, as has been stated, always limited to the situation described ; 
and, as remarked by Fournet, it is more probable that the points at 
which the sign is heard, are those where the stratum of liquid has 
precisely the requisite thinness, the quantity above being too small, 
and below too large. This conclusion is sustained by evidence 
afforded by the percussion and respiratory sounds, found above and 
below the site of the aegophony. Dulness of the sound on percussion, 
and diminution of the respiratory murmur, have been observed to be 
progressively and gradually more marked in descending from a cer- 
tain distance above the limits of the segophony ; flatness and the 
absence of respiration existing at the lower part of the chest.^ As 
exceptions to the general rule, aegophony is occasionally well marked 
in cases in which the quantity of liquid is quite large, sufficient even 
to occasion considerable enlargement of the chest. In the rare 
instances in which aegophony is heard over the greater portion of the 
chest on one side, the explanation offered by Laennec is, that, owing 
to adhesions of the pleural surfaces, at numerous disconnected points, 
the lung is prevented from being pushed upward before the accumu- 
lating liquid, which consequently is diffused over the whole pulmo- 
nary surface, except where the morbid attachments exist, the stratum 
being uniformly of the requisite thinness. In two instances he veri- 
fied the correctness of this explanation by the appearances found 

' Earth and Roger, op. cit. p. 202, edition of 1854. 2 Fournet, op. cit. 



AUSCULTATION IN DISEASE. 273 

after death. The shifting of the seat of the segophony, or its sup- 
pression, when the position of the patient is varied (a point first 
observed by M. Rejnaud, a contemporary with Laennec), is explained 
by the change of relation, which takes place between the lung and 
the surrounding liquid. Assuming that the sign requires an inter- 
vening stratum of fluid of a certain depth, it is not difficult to conceive 
that, having been discovered at a particular part while the patient is 
in the sitting posture, its situation should be found to be movable as 
the body is inclined to one side or the other, or far forward, in con- 
sequence of the relative disposition of the liquid being so changed, 
that the locality in which the necessary physical conditions are 
present, varies. It is also intelligible, that a change of position by 
which the lung displaces a thin stratum of liquid, and comes into 
contact with the walls of the chest, as when a patient, after having 
been examined in the sitting posture, lies on the abdomen, should 
cause suppression of segophony, or a substitution of simply exagge- 
rated resonance or bronchophony, provided the lung be partially 
solidified. These phenomena have been repeatedly observed, but by 
no means uniformly in the cases in which oegophony occurs, which 
accords with the well-known fact, that it is only in a small proportion 
of cases that the level of the efi'used fluid is afi*ected by changes of 
the position of the patient. 

In the vast majority of the instances in which segophony is ob- 
served, it is incident to simple pleurisy. It is very rarely found in 
empyema, the quantity of liquid being too large. It may occur in 
hydrothorax, and be present on both sides of the chest. It has been 
known, as an anomalous fact, to accompany hydro-pericardium. In 
pneumonitis the occurrence of well-marked JBgophony is exceedingly 
rare. It is not, however, very uncommon for the thoracic voice to 
assume more or less of an approximation toward segophony. Under 
these circumstances there is usually exaggerated vocal resonance or 
bronchophony; these signs, in other words, become gegophonic.^ 
Intensity of the thoracic voice, with an segophonic modification, is to 
be regarded as diagnostic of solidified lung conjoined with pleural 
effusion, the vocal resonance in simple pleurisy or hydrothorax being 
rarely much exaggerated. 

'■ It has been proposed by Dr. Christophe to distinguish a sound intermediate between 
aegophony and bronchophony by the title of cegony — a diminutive of aegophony. There 
is not, however, sufficient practical importance in the distinction to warrant the intro- 



1 duction of a new technical term. 

I • 18 



274 PHYSICAL EXPLORATION OF THE CHEST. 

The mechanism of segophony is a mooted point which it would be' 
unprofitable to discuss, and I shall give to this branch of the subject 
but a few words. Laennec attributed the tremulousness of the voice 
to the agitation of the liquid by the act of speaking. It may be 
conceived that the vocal sound transmitted through a stratum of fluid 
under these circumstances, would acquire a corresponding vibratory 
character. Whether this explanation be correct or not, none other 
more satisfactory has been offered. The other segophonic element, 
viz., the elevation of pitch, Laennec accounted for by supposing that 
the bronchial tubes, flattened by the compression of the liquid, are 
made to resemble the mouth-piece of certain musical instruments like 
the bassoon or hautboy, and that the modification of tone was due to 
this condition. This theory is generally deemed unsatisfactory, but 
of the various substitutes that have been proposed, no one has sufii- 
ciently commended itself to be generally adopted. The true rationale 
is yet to be established ; and here, as in other instances in w^hich the 
physical principles involved in the mechanism of signs are undeter- 
mined, the question is one of speculative rather than practical interest. 

In conclusion, from the facts contained in the foregoing account of 
aBgophony, its claims to be recognized as a veritable individual sign 
appear to me to be not less valid than those of pectoriloquy. 
Like the latter sign, it has distinctive traits, by which, when well- 
marked, it is distinguished without difficulty from other signs. More- 
over, notwithstanding the opinion of Skoda to the contrary, it has a 
positive significance, indicating certainly in the vast majority of the 
cases in which it is observed, a special pathological condition, viz., a 
certain amount of liquid efi'usion between the pleural surfaces. Never- 
theless, as stated at the outset, in view of the infrequency of its occur- 
rence in connection with the pathological condition which it repre- 
sents when it does occur, its brief duration, and, in general, the suffi- 
ciency of other physical signs denoting pleuritic efiusion, its clinical 
value is comparatively small, and it might, without much detriment 
to physical diagnosis, be dropped from the catalogue of signs. It is 
to be classed among the curiosities of physical exploration, rather 
than among the phenomena possessing much practical importance. 

In connection with the phenomena incident to the voice may be 
mentioned a novel method of exploration proposed by M. Hourmann, 
in which the auscultator observes the efl'ect of his own voice on the 
chest of the patient. With the ear placed in apposition to the chest, 
but not pressed too firmly against it, more or less resonance and 



AUSCULTATION IN DISEASE. 275 

vibration are perceived, when words are pronounced with a loud voice, 
and in a manner to secure reverberation through the nasal passages. 
To this method M. Hourmann applies the title autophonia.^ What- 
ever clinical value attaches to autophonic phenomena, of course 
depends on certain modifications representing certain morbid con- 
ditions. It is alleged that when the density of the lung is abnor- 
mally increased, the resonance and vibration communicated to the 
thoracic walls are proportionally exaggerated, and hence a disparity 
I between the two sides of the chest in this respect belongs among 
the signs of solidification from pneumonia, crude tubercle, etc. 
Barth and Roger state, as the results of a series of clinical observa- 
tions made with a view to determine the value of this method, 
that in about one-half of the instances in which solidification existed, 
either from the presence of tubercle or inflammatory exudation, 
the autophonic phenomena were more marked ; in the other half no 
appreciable difference existing between the healthy and diseased 
sides ; and that, in general, in the cases in which a disparity was 
apparent, it was slight in degree, being sometimes not appreciable 
without the closest comparison. In no instance did the sound present 
any special character which might indicate something more than the 
fact of increased density of the lung. The information to be derived 
from this method, therefore corresponds to bronchophony ; and it may 
be occasionally useful when the voice of the patient is lost. Except 
in cases of aphonia it seems hardly deserving of attention, and, under 
any circumstances, its value consists in the confirmation which it may 
afford of other auscultatory signs far more reliable. 

Summary of Facts Pertaining to Vocal Signs. — The normal 
thoracic vocal resonance in connection with certain morbid conditions 
may be increased or diminished, and may also present abnormal 
phenomena as regards quality, pitch, etc., of sound. The various 
deviations from health are arranged in four divisions, viz., exagge- 
rated vocal resonance and bronchophony ; diminished and suppressed 
vocal resonance ; pectoriloquy, including amphoric voice, and gego- 
phony. In exaggerated vocal resonance, the diffused, dull, distant 
resounding of the voice, accompanied with more or less vibration or 
thrill, which constitute the characters of the normal vocal resonance, 
are increased in intensity, without any notable alteration in other 
1 1 respects. In bronchophony there is, in addition, an abnormal con- 

* From avTOi and (pwvhv. 



276 PHYSICAL EXPLORATION OF THE CHEST. 

centration and clearness of the vocal sound, the voice seeming to be 
near the ear. The vocal resonance may be slightly, moderately, 
considerably, or greatly exaggerated. Bronchophony, also, in differ- 
ent morbid conditions, may be more or less marked. If slightly or 
moderately marked it is called weak, and if it have considerable or 
sreat intensity, it is called strong bronchophony. Strong broncho- 
phony may exceed in intensity the sound heard over the trachea or 
larvnx. The pitch of sound is not always the same as that of the 
tracheal or laryngeal voice. The vibration or thrill which generally 
accompanies exaggerated resonance, does not necessarily increase in 
proportion to the abnormal strength of the bronchophonic voice. 
Exaggerated vocal resonance habitually exists on the right, contrasted 
with the left side of the chest, and the thoracic voice at the summit 
of the right chest, in front, may even be bronchophonic without 
denoting disease. Exaggerated vocal resonance and bronchophony, 
represent almost invariably morbid conditions, accompanied by in- 
creased density of lung. They occur in connection with the same 
conditions which give rise to the broncho-vesicular, and the bronchial 
respiration. They are generally marked in the second stage of 
pneumonitis, and it is in that disease especially that strong broncho- 
phony is observed. Situated at the summit of the chest on one side 
within a circumscribed area, making due allowance for a normal 
degree of disparity, if the comparatively greater intensity be on the 
left side, they are valuable signs of a tuberculous deposit. Increased 
density of lung from compression, in cases of pleurisy with liquid 
effusion, may give rise to exaggerated resonance, situated over a part 
of the chest corresponding to the space occupied by the condensed 
pulmonary structure ; and this situation, save in some exceptional 
instances, will be at the superior part of the chest. If strongly 
marked bronchophony exists under these circumstances, there is 
reason to suspect that the density of lung involves something more 
than compression, viz., solidification, either from inflammation or 
crude tubercle. Exaggerated vocal resonance may also, in connec- 
tion with other signs, together with symptoms, denote carcinoma of 
the lung, melanotic deposit, extravasated blood or apoplexy, gan- 
grene, serous infiltration, or extra-pulmonic morbid growths. It is 
rare that well-marked bronchophony exists in connection with these 
several affections. As an exception to the rule that exaggerated 
vocal resonance and bronchophony denote increased density of lung, 
both have been observed in cases of emphysema. Their occurrence, 



AUSCULTATION IN DISEASE. 277 

however, in the latter affection is altogether exceptional, the normal 
resonance, as a general rule, being diminished. Dilatation of the 
bronchii"e, accompanied with surrounding solidification, furnishes condi- 
tions calculated to give rise to strongly marked broncliophony. Inci- 
dental to bronchophony, especially when words are whispered, a 
souffle or blowing sound, more or less intense, and high in pitch, is 
a highly distinctive sign of solidification. It is analogous to the 
bronchial respiration, and is marked in some cases of solidification in 
which the latter is obscure or absent. 

Diminution and suppression of the normal vocal resonance are 
incident to the rarefaction of the lung which obtains in emphysema ; 
to obstruction of one of the large bronchi ; to liquid effusion, and the 
presence of air within the pleural sac ; to cavities filled with liquid ; 
and, exceptionally, to some instances of solidification of lung. 

Pectoriloquy is the transmission, more or less completely, of articu- 
late words through the chest to the ear of the auscultator. This 
sign may be present, when various circumstances favorable to its pro- 
duction concur, in cases of pulmonary cavities ; but it is by no means 
a sign distinctive of an excavation, as was held by Laennec. It is 
sometimes well marked in cases of solidification of the lung, in the 
second stage of pneumonitis, and from crude tubercle. When due to 
a tuberculous cavity, the space in which it is heard is circumscribed, 
situated, in the vast majority of cases, at the summit of the chest, 
and it is associated with the cavernous respiration and rales. In 
connection with pulmonary cavities arising from abscess or circum- 
scribed gangrene it is seldom present, the several circumstances 
necessary for its production rarely concurring. It is rarely heard, 
even when tuberculous cavities exist, the various incidental con- 
ditions upon which it depends, being either permanently wanting, 
or only transiently present. A cavernous voice sometimes has a 
ringing, metallic tone, resembling the sound produced by speaking 
into an empty vase. It is then called amphoric. This modification 
is noticed, for the sake of convenience, as an event incidental to pecto- 
riloquy, but it may or may not coexist with transmission of speech. 
Strictly, it is a sign distinct from pectoriloquy, and is more signifi- 
cant of a cavity than the latter. The transmission of articulated 
words, or pectoriloquy, does not sustain any fixed relation to the 
amount of thoracic resonance, or to the strength of the oral voice. 
It may be strongly marked, when the voice is feeble and even extin- 
guished. "Whispering pectoriloquy, however, may accompany solidi- 



21S PHYSICAL EXPLORATION OF THE CHEST. 

fication of lung, as well as an excavation. An amphoric vocal sound 
is more apt to occur in a pleural cavity, in pneumo-hydrothorax, than 
in tuberculous excavations. Ordinary pectoriloquy may be present 
in the affection just mentioned. It may also be well-marked in pouch- 
like dilatation of the bronchise, a lesion of very rare occurrence. 

^gophony is characterized by a peculiar tremulousness, together 
with acuteness of the thoracic voice. These characters are some- 
times due to peculiarities of the oral voice, and care is necessary to 
avoid attributing them to morbid conditions under these circumstances. 
Morbid agophony may be strongly marked, or the thoracic voice 
may be slightly ^gophonic, and the abnormal modifications may have 
every shade of gradation between these extremes. It is most apt to 
be heard at or near the lower angle of the scapula, and if it extend 
from this point, it is generally found within a narrow zone following 
the direction of the ribs toward the nipple. It may, however, be 
heard at any part of the chest, and is sometimes diffused over the 
whole side. It occurs when a small or moderate amount of liquid 
effasion is contained within the plem*al sac. It is therefore incident 
to pleurisy, hydrothorax, and occasionally to empyema and pneumo- 
nitis. If it be sometimes observed in connection with solidification, 
without liquid efiiision, as held by some, these instances are rare ex- 
ceptions to the general rule. 

In the vast proportion of the instances in which it is observed, it 
is incident to simple pleurisy ; but is seldom discovered even in that 
affectioil, owing to the precise amount of liquid requisite for its pro- 
duction existing only in certain cases, and in these only for a brief 
period. When discoverable it is usually at an early period after the 
attack, or late in the progress of the disease. Occurring in connec- 
tion with pneumonitis, it has been observed to disappear from the lower 
scapular region when the body is inclined far forward, and to be 
replaced by bronchophony. Although very rarely well marked 
in cases of pneumonitis, it is not uncommon for the bronchophonic 
voice, in that affection, to present slight tremulousness, with eleva- 
tion of pitch, in other words to manifest an approximation to Jego- 
phony. In cases of pleurisy the sign has been observed to shift its 
seat in the progress of the disease, following the increase, on the one 
hand, and the diminution on the other hand, of the quantity of liquid 
effusion. 



AUSCULTATION IX DISEASE. 279 



PHENOMENA INCIDENT TO THE ACT OF COUGHING. 

Tussive phenomena possess comparatively small importance, inas- 
much as the information which they afford is, in general, obtained 
more satisfactorily, and with greater facility, by auscultation of the 
respiration and voice. Nevertheless, the signs pertaining to cough 
are by no means undeserving of attention, and in some instances 
I' they are valuable auxiliaries in diagnosis. A voluntary act of 
ij coughing is often useful incidentally with reference to other signs. 
ii Sometimes, when from nervous agitation, or awkwardness, a patient 
ij breathes unnaturally and fails to comply with the directions to in- 
j crease the intensity of the respiration, if requested to cough, he invo- 
luntarily takes a deep inspiration preparatory to the act, and at this 
moment the respiratory murmur may be well developed, when before 
it was hardly appreciable. In this way a crepitant rale may perhaps 
be evolved, not otherwise perceptible. By an act of coughing an ob- 
struction seated in some of the bronchial tubes may be removed, and 
the respiratory murmur reproduced in parts of the chest in which it 
had been temporarily suspended. The cause of the absence of the respi- 
ration is thus determined. Instances occasionally occur in which it is 
difficult to decide from the characters pertaining to the sound whether 
a rale emanates from the bronchise or pleura. In such a case if it 
be found to disappear or undergo a material modification after 
coughing, it is bronchial, but if it remain unaffected it is likely to be 
pleural. 

The tussive sounds incident to health have been briefly described. 
Those heard over the chest undergo certain modifications in conse- 
quence of intra-thoracic disease, and certain adventitious sounds may 
also be produced by coughing. Both species of signs, ^. e. modified 
natural sounds, and new sounds, are few in number compared with 
those derived from respiration and the voice ; moreover, each of the 
tussive signs will be found to have its analogue among those incident 
to respiration. 

All the phenomena incident to the act of coughing which are prac- 
tically important, may be arranged into two classes, viz., 1. Bronchial 
Cough ; 2. Cavernous Cough. 

1. Bronchial Cough. — The tussive sound is bronchial, or, as it 
is also termed, tubular, when, in place of the feeble, short, diffused 
sound, unaccompanied by much, if any, impulse or shock, constituting 
the tussive phenomena heard over the chest in health, the ear receives, 



280 PHYSICAL EXPLOKATION OF THE CHEST. 

a concussion more or less forcible, together with a blowing sound, 
more or less intense, prolonged, concentrated, elevated in pitch, con- 
veying the impression of nearness. These characters are similar to 
those which belong to the phenomena produced normally within the 
trachea by the act of coughing. The analogue of the bronchial or 
tubular cough is the bronchial respiration, and it is usually associated 
with exaggerated vocal resonance or bronchophony. The characters 
which have just been mentioned are in fact identical with those which 
belong to the expiratory sound in the bronchial respiration. They 
may be strongly marked in some cases in which the bronchial respi- 
ration is feeble, and hence the tussive sign may be valuable, not 
only as confirming, but as a substitute for the latter. It represents 
precisely the same physical conditions as the bronchial respiration 
and bronchophony. The bronchial cough, therefore, occurs especially 
in the second stage of pneumonitis ; next in frequency and promi- 
nence, in connection with crude tubercle ; also in pleurisy over the lung 
rendered dense by compression, in apoplectic extravasation, oedema, 
and dilatation of the bronchial tubes, etc. The mechanism of its 
production involves the same physical principles as the bronchial 
expiratory sound. It originates within the trachea and bronchial 
tubes ; the column of air therein contained being expelled with force 
by the violent and quick expiration, the vocal chords at the same 
time approximated, and the blowing sound transmitted with greater 
intensity to the ear of the auscultator in consequence of the density 
of the intervening pulmonary structure. 

2. Cayerxous Cough. — The cavernous cough embraces three 
distinct varieties. The first occurs when a pulmonary cavity is 
empty, i. e. free from liquid contents. Under these circumstances 
the act of coughing gives rise to a shock, often much more marked 
than in bronchial cough. The head of the auscultator seems some- 
times to be raised by the force of the impulse. It is accompanied by 
a blowing sound more or less intense and prolonged, probably always 
lower in pitch than the expiratory sound in the bronchial respiration, 
or the souffle accompanying whispered words ; and conveying the 
impression of its being produced within a hollow space. These cha- 
racters, contrasted with those belonging to the bronchial cough, are 
distinctive ; but the discrimination involves, in addition, the fact that 
they are found within circumscribed limits ; and, inasmuch as in nine 
cases in ten pulmonary excavations are due to tuberculous dis- 



AUSCULTATION IN DISEASE. 281 

ease, they are almost invariably situated at the summit of the chest, 
in the infra-clavicular region. These two points, viz., the limited area 
and the locality, will serve to distinguish a cavernous from a bron- 
chial blowing, taken in connection with the intrinsic diiferences in the 
characters of the two sounds. The pathological significance of this 
variety of cavernous cough is, of course, the same as that of simple 
cavernous respiration : the latter is its analogue. The one may be 
well marked, when the other is not distinctly appreciable. A caver- 
nous blowing produced by the act of coughing may, therefore, some- 
times be available, when with ordinary respiration it is not readily 
discovered. If both are present, they serve mutually to confirm each 
other. The mechanism, it is obvious, is the same in either instance. 
The circumstances which are favorable to the presence of both are 
identical, viz., in addition to emptiness of the cavity, its size, commu- 
nication with the bronchial tubes, the latter being unobstructed, 
superficial situation, etc. 

The second variety is amphoric cough. A cavernous cough be- 
comes amphoric when it has a ringing, m.etallic tone, resembling that 
which constitutes a variety of the respiratory and vocal sounds to 
which the same title is applied. An amphoric cough may be imitated 
by coughing over the mouth of an empty vase. It occurs under the 
circumstances which give rise to amphoric voice, viz., in connection 
with a pulmonary cavity of large size, with rigid walls, or with 
pneumo-hydrothorax involving perforation. The significance and the 
mechanism are in all respects the same. 

The third variety is an adventitious sound produced when the cavity 
is partially filled with liquid. The analogue of this kind of caver- 
nous cough is the gurgling rale accompanying respiration. Under the 
conditions which are necessary for the production of gurgling, the 
liquid contained within the cavity is more violently agitated by the 
movements involved in coughing, and a loud splashing sound is fre- 
quently produced. This sound, well marked, is more readily than 
gurgling distinguished from the bronchial mucous rales, and if situated 
at the summit of the chest, within a circumscribed area, it is the most 
significant of the physical signs denoting a tuberculous cavity of con- 
siderable size. It will be likely to alternate with the dry variety of 
cavernous cough, with cavernous respiration, possibly also with 
pectoriloquy ; and to coexist with gurgling ; but it may be present 
when none of the cavernous signs just mentioned are distinctly marked. 



282 physical exploration of the chest. 

Metallic Tinkling. 

The sicrn called metallic tinkling has not been included among the 
auscultatory phenomena incident to respiration, the voice, or cough, 
because it does not pertain exclusively to either, but is common to all. 
It is an adventitious sound, resembling the rales in the fact of its 
production within the chest being always due to disease, but as will 
be seen presently, an analogous sound is sometimes transmitted from 
the stomach. As an isolated sign it is one of the very few that pos- 
sess a significance almost pathognomonic ; and its distinctive charac- 
ters are singularly marked and appreciable. 

The title metallic tinkling is eminently descriptive of the charac- 
teristic sound. Laennec compared it to the sound emitted by " a cup 
of metal, glass, or porcelain, when gently struck with a pin, or into 
which a grain of sand is dropped;" and, again, to the " vibration of 
a metallic wire touched by the finger." Other illustrations employed 
by different writers, are the tinkling of a small bell ; shaking a pin 
in a decanter ; dropping small shot into a brass basin ; the ebullition 
of fluid in a glass retort or flask. An apt comparison by Dr. Bigelow 
is to the " note of short brass wire in certain children's toys." In all 
these analogies there is a common feature, viz., a high-pitched, clear, 
abrupt, short, silvery tone. There is no difficulty in practically de- 
termining the presence of the sign ; and by a description alone an 
observer is prepared to recognize it at once, the first time it is pre- 
sented to his notice. The tinkling may consist of a single sound, or, 
more commonly, of two, three, or more sounds, distinct, but following 
in quick but irregular succession. As already stated, the sign may 
accompany respiration, speaking, and coughing. It is oftener pro- 
duced by the two latter than by the first, and more especially attends 
the act of coughing. The act of deglutition may also occasion it. 
This fact was first noticed by Dr. Charles T. Hildreth, of Boston,^ in 
1841. It has since been confirmed by other observers. Succussion, 
or shaking the body of the patient, is also found in many cases to give 
rise to it, and it is sometimes observed to occur in consequence of a 
change of position, from the horizontal to the vertical. When it 
accompanies respiration, it is more apt to be produced by the inspira- 
tory than the expiratory act, although it may be present with either, 
or both. It occurs at the close of inspiration, the tinkling sounds 

* Vide Descriptive Catalogue of the Anatomical Museum of the Boston Society for 
Medical Improvement, page 124. 



AUSCULTATION IN DISEASE. 283 

frequently being continued into the expiration. Sometimes when it 
is not heard with ordinary breathing, it becomes developed by a forced 
inspiration. It rarely accompanies each successive act of respiration, 
but is heard at irregular intervals. It is important to bear in mind 
the fact that it may be found in connection with the voice and cough 
when it does not attend the respiration ; and that it may be produced 
by coughing, when it is not observed either with the voice or respira- 
tion. Its situation is commonly at the middle third of the chest, 
anteriorly, posteriorly, or laterally. It is sometimes confined to a 
circumscribed space at the summit. In other instances it is diffused 
over the entire chest on one side. In the progress of the same dis- 
ease it may be found to shift its seat, being heard at first over the 
middle of the chest, and afterward at a higher point. Its duration 
in diff'erent cases differs. It may be transient, or persist for a long 
time. In constancy it is also variable. Sometimes it appears, ceases 
for a time, and is again reproduced ; or, it comes and goes at irregular 
intervals. The sound in some instances appears to be near the ear, 
and in other instances more or less remote. Finally, in sharpness 
and quality of tone, as well as intensity, there are variations which 
are clinically unimportant. For the most part the diJBferences just 
mentioned are explicable by reference to varying circumstances 
connected with the physical conditions upon which the sign is depen- 
dent. 

In determining the presence of this sign, there is scarcely a possi- 
bility of confounding it with any other of the auscultatory phenomena. 
The only liability to error arises from the fact that a metallic tink- 
ling sound, as already intimated, is occasionally produced within the 
stomach, and transmitted, so as to be apparent on auscultating the 
inferior portion of the left chest. Mere gastric tinklings, however, 
are never so frequently repeated or persisting as are generally those 
produced within the chest. They occur irrespective of either respi- 
ration, voice, or cough, and this alone suffices for the discrimination. 
Moreover, the associated signs and symptoms will always show the 
absence of the intra-thoracic affections to which it is incident when 
produced within the chest. 

The physical conditions involved in the production of metallic 
tinkling are sufficiently established. It requires the existence of a 
cavity of considerable size, containing a certain quantity of liquid, 
the remainder of the space being filled with air or gas. Skoda contends 
that the presence of liquid is not essential — an opinion he is in a 



284 PHYSICAL EXPLORATION OF THE CHEST. 

measure bound to entertain for the sake of consistency with his pecu- 
liar theoretical notions respecting the mechanism by which the sign is 
produced. Observation and experiment appear to show that as the 
rule, with, perhaps, some exceptions, a certain amount of liquid is 
requisite. Laennec supposed communication of the cavity with a 
bronchial tube to be not a necessary condition, as is incorrectly stated 
by some writers, but to exist in all the cases in which the sign is pre- 
sent with very rare exceptions.* Subsequent observations have shown 
that it is not indispensable, although much more favorable to its pro- 
duction by respiration, speaking, and coughing; and, in fact, as stated 
by Laennec, the instances in which the sign occurs, when such a 
communication does not exist, are extremely infrequent. The essen- 
tial conditions, viz., the existence of a space of considerable size con- 
taining air and liquid, are furnished in pneumo-hydrothorax and pul- 
monary excavations. Metallic tinkling represents invariably one of 
these two affections, excluding cases of simple pneumothorax as a 
form of disease of such exceeding infrequency that it may practically 
be disregarded. It does not occur in other forms of intra-thoracic 
disease. It is a rare incidental sign of a pulmonary cavity. It 
occurs when the excavation is large, with rigid walls, and then only 
at particular times, when the relative proportions of liquid and air 
happen to be favorable. From the infrequency of its occurrence, 
and the sufficiency of other signs for the diagnosis, it is clinically of 
very little value in connection with this lesion. When produced 
within a pulmonary excavation, the latter, certainly, in the vast ma- 
jority of cases, if not without exceptions, proceeds from tuberculous 
disease. Hence, in the few instances in which it is due to this cause, 
the sound will be found confined within a circumscribed space at the 
summit of the chest. In a practical point of view, it may almost be 
said that the sign is pathognomonic of pneumo-hydrothorax. It is 
generally present in cases of that affection. This fact, taken in con- 
nection with its extreme infrequency in phthisis, would almost justify 
the practitioner in predicating the diagnosis upon the presence of this 
isolated sign, especially if it be situated at the middle third, or dif- 
fused more or less over the chest. But dependence on this sign 
exclusively is never necessary, the concomitant signs, denoting 
pneumo-hydrothorax, being quite distinctive, as has appeared from 
the phenomena incident to percussion and auscultation, which have 
been already considered. 

' Yide op. cit., Am. Ed. of Forbes's Translation, Edition of 1830, pages 526 and GO. 



AUSCULTATION IN DISEASE. 285 

Although the physical conditions giving rise to this sign are so 
well understood, and its pathological significance so precise and well- 
defined, the mechanism of its production has been the subject of 
much discussion and diversity of opinion. We have here, however, 
another exemplification of the fact, that the clinical value of physical 
signs is not dependent on our ability to adduce all the physical prin- 
ciples which their production involves. Different writers may differ 
widely as respects the latter, but there is very little room for dis- 
crepancy of opinion concerning tho pathological or anatomical rela- 
tions of metallic tinkling. To discuss the various hypotheses which 
^jhave been offered in explanation of the sign, would require more 
■ space than the importance of the subject, in a practical point of view, 
merits, and I shall therefore restrict myself to a brief notice of those 
which appear to be sustained by observation and experiment. Laen- 
nec attributed its production, in certain instances, to drops of fluid 
falling from the upper part of the space, upon the surface of the 
liquid below. He offers this explanation in the cases in which the 
sound is observed to follow change from the recumbent to a sitting 
posture, and implies that it is not intended to apply to all other 
instances, but without giving any special rationale. That the falling 
of drops of liquid upon a quantity of liquid within a cavity, will give 
rise to a tinkling sound, he demonstrated by injecting, in small quan- 
tities at a time, a fluid into the chest of a patient with empyema 
after the operation of paracentesis. An imitation of the sound 
I takes place, when drops of liquid are made to fall into a vessel one- 
third full of water. Another explanation, suggested by Dr. Spittal, 
of Edinburgh, in 1830, and demonstrated by experiments reported by 
Dr. Jacob Bigelow, of Boston,^ Dance, Fournet, and Barth and 
Roger, in France,^ is, that the air, finding its way through a fistulous 
orifice opening below the level of the liquid, rises to the surface of 

I the latter, forming bubbles, which break and give rise to a tinkling 
sound. The experiments by Dr. Bigelow were made on the bodies of 
subjects dead with pneumo-hydrothorax, and with a recent bladder or 
stomach partially filled with liquid. When a catheter was intro- 
duced through an opening into the chest, and carried below the sur- 
face of the liquid, air blown through the instrument produced an 
exquisite metallic tinkling at the explosion of each bubble, resembling 

' Vide American Journal of Med. Sciences, 1S39, and a recent volume by Dr. Bige- 
low, entitled Nature in Disease, etc. 

2 Vide Treatises by Earth and Roger, French edition of 1854, and by Fournet. 

I 



286 PHYSICAL EXPLORATION OF THE CHEST. 

the sound heard during life. This result obtained only when a 
few ounces of liquid were contained within the chest. If the quan- 
tity was increased by injection to the amount of two or more quarts, 
a bubbling sound was alone produced. Tinkling also was produced 
by repeating Laennec's experiment, viz., letting fall drops of water 
from above upon the liquid in the chest. A bladder, and afterward 
a stomach, each containing a few ounces of water, and then inflated 
until thoroughly distended, were used to produce an imitation of the 
characteristic sound by a similar method.-^ " Whenever the inflating 
tube was pushed below the surface of the liquid, and the inflation 
continued so as to produce bubbles, a sharp tinkling was heard upon 
the explosion of every bubble by the ear applied, as in auscultating, 
to the outside of the bladder. In this experiment, the sound becomes 
more exquisitely metallic, in proportion as the tension of the bladder 
is increased by farther inflation." Eournet produced similar results 
by injecting, during life, in a patient on whom had been performed 
the operation of paracentesis, air through a female catheter carried 
below the level of the liquid. This experiment was repeated several 
times.^ Barth and Roger, on repeating the experiments made by Dr. 
Bigelow with a bladder, found the same results.^ This explanation, 
it is obvious, will only apply to the instances in which a communica- 
tion exists between the cavity and the bronchial tubes, or externally 
by means of an opening through the thoracic walls. It is difficult 
also to understand the persistency of the sign when thus produced, 
since the accumulation of air above the level of the liquid must soon 
establish an equilibrium of pressure between it and the external 
atmosphere, so that bubbles would no longer rise and explode in the 
manner described. Simple agitation of the liquid, is competent to 
give rise to the sound. This is proved by succussion of the body of 
patients with pneumo-hydrothorax, both during life and after death.'' 
A sufficient amount of agitation, it may be imagined, takes place 
with respiration, but more especially with the acts of speaking and 
coughing. Again, experiments appear to show that the bursting of 
bubbles of mucus at the opening of a fistulous orifice situated above 
the level of the liquid, may occasion a sound resembling, but not 
absolutely identical with metallic tinkling.^ Without citing other 

' The bladder or stomach employed in these experiments should be recent. 
2 Op. cit. t. 1, page 378, et seq. 3 Op. cit, ed. of 1854, page 239. 

* Vide Dr. Bigelow's experiments, op. cit. 
5 Vide experiments by Bigelow, Fournet, and Barth and Roger. 



I 



AUSCULTATION IN DISEASE. 287 

j explanations, less satisfactorily established, the mechanism of the 
i sign probably involves the several modes just mentioned, alternating 
i| with each other, or more or less combined together.^ Either explana- 
I tion, taken singly, is met by objections derived from instances in 
jj which the sign is observed to take place ; but collectively, they 
' render its production intelligible, under the different circumstances 
pertaining to the physical conditions upon which it depends. Adopt- 
ing this view of the subject, a frequent, perhaps the most frequent 
i cause of the phenomenon, is the explosion of bubbles of air on the 
! surface of the liquid. In the rare instances in which no communica- 
1 tion exists between the pleural cavity and the bronchial tubes, it is 
i probably due to the agitation of the liquid, portions being thrown 
upward and falling back upon the surface. Under these circum- 
1 stances, the sign will not be likely to accompany respiration, but only 
! the voice and coughing, possibly being confined to the latter act. In 
[j this mode it is produced by change of position, or movements of the 
I body. It is not difficult to conceive that the flocculent false mem- 
llbranes at the superior part of the space, may retain a small quantity 
! of the liquid for a short period, after rising from the horizontal to 
■; the upright posture, which falls in drops, as supposed by Laennec. 
If there be fistulous communication with the bronchi^e, and the 
opening be above the level of the liquid, the sound is probably 
owing to the bursting of bubbles at the orifice opening into the 
cavity. Different modes of the production of metallic tinkling 
may be conjoined, i. e. may operate in combination. Thus the 
sounds due to explosive bubbles and agitation of the liquid may 
occur simultaneously. It is also easy to understand that they may 
succeed each other in alternation. For instance, the orifice may at 
one time be above, and at another time below, the level of the liquid, 
owing to variations in the proportionate quantity of the latter. The 
orifice, also, or the bronchial tubes leading thereto, may at times be 
obstructed, and at other times pervious ; an aperture may at one 
period of the disease exist, and afterward become permanently closed. 
These varying circumstances will serve to explain the variations in 

^ The reader who may desire a fuller account of the experimental researches which 
have been made in order to elucidate the mechanism of the production of metallic 
tinkling, will find them detailed at length by the several authors referred to. I have 
deemed it inconsistent with the practical objects of this work to yield the space which 
their introduction at length would require. Skoda attempts to account for the sign by 
his favorite theory of consonance, but its application in this instance is even less satis- 
Ij factory than to the explanation of other auscultatory phenomena. 



Z5T. 



qaalit~. ir'TTs: ~ : "iMmhi, dmmlmi, pere: 
lieeii 5 T T 1 : r i : r the deseiiplioii cf in 

Mf: ■- "-'. - "- :. - : . - : ' ^ -^TMailfly xssomtm 
t: ' ~ ~ : : : - ' i . , -- '■ "^ "~ srane wiitiar? 

t::1^~ -_:_-.. ': '_..tt -.i? last: leenti': 

anddia^ioeli: _ ^ :::.= It :„t ■ zir. As :t^;t:-= :it :..':'; ;ii- 

id^ititj. Mc:t:~t:-. _:rT: tI' ^ _ ;^-: • . :;;..._.:.; l^ :.t -i" .'t.. :rr- 
tainly in tibe z: t : l^^ - : : : = _ : es. Meiallie fintrling , wtA. 

T€3rj few exieeT - : - : : " T.Miiiiig ml idle same tiuie 

air and liquid. _ _ : in fme d liie mc'Cf s hj 

wMdk it is supposr -ii^ by bubbles c^lo'drDg aft 

the opening <^ a z the presence of ' ~ 

withm the eawiij^ is fistnloas eommDiL: 

either iFifh a> pohr : . _ ~ : _. "" .enral caiity, nic»r r t - ' 

da%^ liith the la;!: - laepresraiee :: z ; 

or less Uqaid ; ai: _ „ :r -r^nced, a, z: : : ^ 

liqpnd is required : -iidi exc] :ie jit 

the point of eon: _ „ :_ 

TOiee, on the othti j-LCiii.^ ai ^a iuyjirv-s : 
idth onpljeaTides ifithoiiit Intindiial <y. :. 
sepinm onfy inteiroie between the ^acr „ 

when^ as is geneiallj the case, a, oonnii : 
present in lie caiity, the latter does n-o: 
of araphtinie r^piration, Toiee, and etdiz _ ~ t : : : miy 
lai^ ^«^CHti(m of instanees, the liquid - : i 

the prodnettion of metallie tinkling. :-?. 

and ©oc^ danand <mly a ^aee of cobls :: t z 

Metallie tinkling, occasiraied, as has bee _ .:i "^ ii 

rising to the snr&iee dF a. liqind, or by : : : ^ by 

agitation of a nia^ of liquid, cannot ta z t t z f p- 

tiimal mode mentioned, in a cavity conta:z _ z :i _ _ rse 

statem^its are shown to be eorreet by : m 

wit^ the- expeiiments by Bigelow and <: : z ; . - " - _ : ; z . 7 : t : t z : : zas 
jngt been made. In sobjeets dead v::_ z :z^ zis, or 

patients «Hi winoni had been padtised tz z'esis, 

and with a recent bladi^r or stomaeL z „ zlj 

wliener(ra' air was Mown throng a tnlr : r ea»ity 

and earned aboTe ^diG level <^ the liqiiicu a ^^uIiul ^LiiiuugOf^iiifi t{» doe 

■WaMae, 



AUSCULTATION IN DISEASE. 289 

amplioric respiration was heard on applying the ear to the chest, or 
to the distended membrane ; and never the metallic tinkling, except- 
ing saliva was carried into the tube, producing bubbles at its ex- 
tremity. Although, therefore, this sign is so often associated with 
the amphoric modifications of respiration, voice, and cough, the 
phenomena cannot be properly considered as essentially the same. 

Summary. 

I Metallic tinkling requires, as a general rule, with perhaps some 
jj rare exceptions, a cavity of considerable size containing air and a 
|| certain quantity of liquid. In the vast proportion of cases the 
cavity in which it occurs communicates with the bronchial tubes. It 
is occasionally produced within tuberculous excavations, but occurs in 
a large proportion of cases of pneumo-hydrothorax. It is almost 
pathognomonic of the latter affection, and is found frequently to co- 
exist or alternate with amphoric respiration, voice, and cough. 



Abnormal Transmission of the Sounds of the Heart. 

In auscultating the chest in health, the sounds of the heart may 
be heard in all directions, at a distance more or less remote from the 
prsecordial region, the extent of their diffusion and their intensity 
differing considerably in different persons. Provided the intra- 
thoracic organs are free from disease, it may be assumed that the 
loudness of the heart-sounds is proportionate to the proximity to the 
heart ; and they will be found to diminish gradually, as the ear is 
removed from the prsecordia, until, at length, they cease to be appre- 
ciable. If, therefore, they are discovered to be more intense at a 
certain distance, than at any intermediate point, it shows that a 
I morbid condition exists, in consequence of which they are abnormally 
transmitted. For example, if the sounds are heard with greater 
distinctness and force just below the left clavicle, than at any point 
between this situation and the prsecordia, it follows that there is an 
abnormal transmission to the part designated. Again, if the sounds 
have greater intensity in the right than the left infra-clavicular 
region, the former being considerably farther removed from their 
source, it is due to a morbid condition. Abnormal transmission of 
the sounds of the heart may thus become a sign of disease. It is 

19 



290 PHYSICAL EXPLORATION OF THE CHEST. 

cliieflj with reference to the diagnosis of tuberculous disease, that 
this sign possesses clinical value. In that connection it is worthy of 
attention. The deposit of tubercle probably renders the portion of 
lung affected, a better conductor of the sonorous vibrations emanating 
from the heart. Another reason why the heart-sounds are louder 
over a deposit, in certain cases, is the diminution or suppression of 
the vesicular respiratory murmur in the part affected. The examples 
just cited in illustration, are actually presented in some instances of 
phthisis. A tuberculous deposit at the apex of the left lung may 
occasion an abnormal transmission to below the left clavicle, rendering 
the sounds more intense there than at any point between this situation 
and the prsecordia, and even more intense than in the latter region. 
Again, a tuberculous deposit at the apex of the right lung, may . 
cause the sounds to be heard with distinctness in the right infra- 
clavicular or scapular regions, when they are inappreciable in the 
corresponding regions on the left side ; or they may be decidedly 
more intense at the summit of the right, than of the left chest. The 
latter is not infrequently observed in cases of tuberculous disease. 
The sign, under these circumstances, furnishes strong presumptive 
evidence in itself, of the existence of phthisis ; and it is entitled to 
considerable weight in combination with the various other signs, which 
concur to establish the diagnosis of that affection. To constitute 
this a sign of tuberculosis, however, a condition is to be observed 
upon which we have seen to depend the significance of various other 
signs, viz., it must be limited to a circumscribed area at the summit 
of the chest, in front or behind. 

In consolidation from pneumonitis, and in cases of liquid effusion 
within the pleural sac, the sounds of the heart are unduly audible. 
In connection with these affections, the abnormal transmission ex- 
tends over a much larger space than in the cases of tuberculosis, in 
which the sign occui's. In the diagnosis of these affections its value 
is insignificant, other signs being abundant and positive. 

Observed within a more limited space, but not confined to the 
superior portion of the chest, this sign may coexist with others of 
much greater reliability, denoting solidification from extravasated 
blood, carcinoma, etc. 

An abnormal diminution, as well as increase of the transmitted 
heart-sounds, may constitute a physical sign of disease. Emphysema 
lessens the conducting power of the lung, and as one of the results of 
this affection, the sounds may be found to have greater intensity at a 



AUSCULTATION IN DISEASE. 291 

certain distance from the prsecordia, than at another situation less 
11 remote. Dr. Walshe states that in a case of intense emphysema of 
ij the left lung in which the disease was limited, and especially marked 
ji at the posterior aspect of the chest, he found the heart-sounds consi- 
derably more distinct posteriorly on the right than on the left side, 
|i there being no evidence of induration of the right lung to intensify 
the sounds on that side. The disparity here was attributed to an 
jl abnormal diminution of the transmission of the sounds to the posterior 
surface of the left chest, the right side remaining in a normal condi- 
tion in this respect. Without knowledge of the fact that the trans- 
mission may thus be abnormally diminished, a normal intensity may 
be mistaken for a morbid sign. 

Abnormal feebleness of the sounds of the heart in the praecordial 
region is an effect of emphysema affecting the left lung. The enlarge- 
ment of the lung from the over-distension of the cells causes it to 
extend over the whole of the surface of the heart, instead of the latter 
organ being in contact with the walls of the chest within a certain 
space. Under these circumstances it is easy to perceive that the 
I sounds of the heart must be transmitted to the ear applied over the 
prsecordia with less intensity than in a normal condition. Abnormal 
diminution of the sounds of the heart in the praecordia, in connection 
with undue clearness of the percussion resonance, and absence of the 
heart's impulse, denotes that a thick layer of lung intervenes between 
the organ and the thoracic parietes. 

The cardiac sounds may not only be transmitted with undue inten- 
sity to different portions of the chest, but they may emanate from 
other situations than the praecordia, in consequence of displacement of 
the heart. This will be found to enter into the history of pleurisy 
with large liquid effusion, and of pneumo-hydrothorax. Finally, a 
bellows arterial sound is sometimes heard within a circumscribed 
space at the summit of the chest on one side, not transmitted from 
the heart, but limited to the subclavian artery, probably produced by 
pressure upon the artery, of the apex of the lung consolidated by 
tuberculous deposit. Dr. Stokes was the first to call attention to. the 
, occasional occurrence of this, as a physical sign of phthisis. He 
thinks that sympathetic irritation of the artery is sufficient to occasion 
it without pressure, basing this opinion on its intermittency, and his 
having observed it to subside after copious haemoptysis, and leeching 
in the subclavian or axillary regions.^ Whatever may be the expla- 

' Stokes on the Chest, American edition, 1844, page 385. 



292 PHYSICAL EXPLORATION OF THE CHEST. 

nation, the occasional occurrence of a hruit de soufflet, in connection 
with a tuberculous deposit of the apex of the lung, the sound being 
wanting in the brachial artery of the same side, in the heart, aorta, 
and carotid, and in the opposite subclavian, is a fact important to be 
borne in mind. 

HiSTOEY. 

Although allusion to listening in order to discover abnormal sounds 

within the chest may be found in the works of various writers even 
as ancient as those of Hippocrates, yet to so little extent was this 
method of investigation previously employed, and so insignificant had 
been its results, that the honor of the discovery justly belongs to 
Rene Theophile Hyacinthe Laennec, a native of Lower Brittany, 
,born in 1T81. The discovery was made by Laennec, while acting as 
chief physician to the Hospital !N'ecker, in Paris, in 1816. It was 
communicated to the French Academy of Sciences in a memoir read 
in 1818, and during the same year was published the great work 
entitled " De V Auscultation 3Iediate, ou Traite du diagnostic des 
Maladies des Poumons etdu Coeur, fonde princijpalement sur ce nou- 
veau moyen d' exploration.'' In the introduction to this work, Laennec 
announces the discovery, and relates the circumstance which led to it in 
the following words : '' In 1816, I was consulted by a young woman 
laboring under general symptoms of diseased heart, and in whose 
case percussion and the application of the hand were of little avail on 
account of the great degree of fatness. The other method just men- 
tioned being rendered inadmissible by the age and sex of the patient, 
I happened to recollect a simple and well-known fact in acoustics, 
and fancied, at the same time, that it might be turned to some use 
on the present occasion. The fact I allude to is the augmented im- 
pression of sound when conveyed through certain solid bodies — as 
when we hear the scratch of a pin at one end of a piece of wood, on 
applying one ear to the other. Immediately, on this suggestion, I 
rolled a quire of paper into a kind of cylinder, and applied one end 
of it to the region of the heart and the other to my ear, and was not 
a little surprised and pleased to find that I could thereby perceive 
the action of the heart in a manner much more clear and distinct 
than I had ever been able to do by the immediate application of the 
ear. From this moment I imaorined that the circumstance mio:ht 
furnish means for enabling us to ascertain the character, not only of 



AUSCULTATION IN DISEASE. 293 

the action of the heart, but of every species of sound produced by the 
motion of all the thoracic viscera, and, consequently, for the explora- 
tion of the respiration, the voice, the rale or rhonchus, and perhaps 
even the fluctuation of fluid efi'used in the pleura or pericardium. 
j With this conviction I forthwith commenced at the Hospital Necker 
jl a series of observations which have continued to the present time. 
The consequence is, that I have been enabled to discover a set of 
jl new signs of disease of the chest, for the most part certain, simple, 
j and prominent, and calculated, perhaps, to render the diagnosis of 
! the diseases of the lungs, heart, and pleura, as decided and circum- 

I stantial as the indications furnished to the surgeon by the introduc- 
i tion of the finger or sound, in the complaints wherein these are 

II used."^ 

It is a curious fact, that the suggestion which led to the discovery 

was an error in physics. The sound, in the illustration cited in the 

foregoing paragraph, is not augmented, but merely conducted vastly 

I better than through the atmosphere ; and it is now well established 

jl that intra-thoracic sounds are heard with the ear applied directly to the 

j chest, as well as, if not betterj than through the intervening medium, 

j or stethoscope, to which Laennec attached so much importance as to 

call the new method by the title of mediate auscultation. 

In the remarkable work, the title of which has been given, the 
I various phenomena revealed by auscultation are named, described, 
I classified, explained, and their relations to morbid conditions deter- 
mined with a degree of completeness and accuracy, constituting it an 
imperishable monument of the industry and genius of the author. 
To such an extent was the science of auscultation perfected in the 
hands of its founder, that a considerable portion remains to the pre- 
sent moment unchanged, notwithstanding the labors of a host of 
observers, who have striven to enlarge the boundaries of its applica- 
tion to the diagnosis of diseases. Rarely, if ever, has there been an 
instance of a discovery of equal importance in which so little was left 
by the discoverer to be performed by others. Moreover, as an ex- 
ception to the general rule, the gratification was accorded to Laennec 
of witnessing the acknowledgment of the value of his discovery, and 
its adoption by the most intelligent of his contemporaries. Never- 
theless, the labors of those who have devoted attention to the culti- 
vation of this department of medical science, since the discovery by 
Laennec, have by no means been without useful results. Some errors 

^ Forbes' translation. 



'2M 



FET5I 



hxve been eorreeted, ans 
ajgpeeis, important par:^ 
diagn€sk of IliaiaiGifi &- 
<^e by eonliibiitioiiis tc 
mentioBed in Ibe foreg 
searvicim witb "whieh !&€:: 
Laennee died, in 18i 
&rtj-£^ jear of bis ag 



fnomeiia 



CHAPTER ly. 

INSPECTION. 

Physical exploration, by means of inspection, consists in an ocular 
examination of the chest, in order to discover deviations from sym- 
metry, or any abnormal appearances, as regards size and form, and 
also visible alterations of the natural movements incident to respi- 
ration. Important physical signs are determined by this method. 
In the relative value of the phenomena which it furnishes, it ranks 
next to auscultation and percussion. In the practice of physical 
exploration, this method should generally be first employed, because 
its results are to be taken into account in estimating the importance 
which belongs to the phenomena obtained by the methods which have 
been already considered. 

Whenever a careful inspection is necessary, it is most convenient 
and satisfactory to survey the chest divested of all clothing. This 
may be done with propriety if the patient be of the male sex ; but a 
due regard to delicacy requires that the entire chest of the female 
shall not be uncovered. To secure the advantages of a complete exa- 
mination without offence to modesty, different sections may be in- 
spected separately. The lower portion of the chest anteriorly, 
including the mamma, may be covered, while the upper part is 
exposed ; and afterward the upper part, with the mamma, covered, 
while the lower portion is denuded. 

This will suffice for all the purposes of exploration, without insist- 
ing on an exhibition of the mammary region. The examination may 
be made while the patient is recumbent, or sitting, or standing. 
When circumstances render it practicable and proper, the last-men- 
tioned position or the second is preferable to the first. Sitting or 
standing, the patient should be placed opposite a good light, and 
requested not to incline the body in either direction ; the attitude 
should be perfectly easy, the muscles relaxed, the upper extremities 
hanging loosely by the side, while the practitioner first surveys the 
chest at a suitable distance directly in front, and afterwards on each 
side, obtaining a view in profile. The anterior and posterior surfaces 



296 ?zrsiCAL zxplihaiio:^ :r izz czzsi. 

I 
of the cliei; aie to be inspected o>>serYing the same precautions. 

The examination of the poster::: :::::e, especially, is most conve- 
niently made when the patient s:: : . I: :h.e recmnhent attitade he 
necessary, on acconnt of the feet^ei^cis :i :i.e patient, or other causes, 
care is to he ohserved that the hody rests on an eren plane. In- 
attention to this point may affect materially the resnlts of the exami- 
nation. 

In the size, configuration, &c., of the chest, considerahle differences 
are ohserred in different persons free from thoracic disease. It is 
impossible to ^ upon a normal standard, which shall serre as a 
criterion by which to estimate either the existence or the degree of 
abnormal deviations. The phy^cal signs famished by inspection, as 
a general rnle, are determined by obserring a want of ::rTT":iL- 
denoe between the two sides. Taking adTantage of the fac: :L::. ::r 
the most part^ intra-thoracic diseases are either confined to one side, 
or affect one side more than the other, and assnming that in a normal 
condition the two sides are ^rmmetrical (which, with certain excep- 
tions, observation shows to be correct), a marked disparity in the 
visible appearances is fairly presumed to be the effect of disease. 
Moreover, observation teaches that diseases tend to produce different 
effects upon the size, form, and movements of the chest, and that 
different affections, individually, are characterized by their own special 
alterations. Hence, the source of the significance of the latter as 
physical sigi. = . Taeir value, as indices, of certain phy^cal conditions, 
rests on tz. : : :acy of their connection with these conditions. 

Most of ;.: : : := -^bich would fall under the head of [inspection in 
health hav^ : : .t -en stated in the introduction to this work. It 
is important to take cognizance of certain variations from the rule of 
perfect symmetry of the two sides, occurring very frequently not 
only in health, but without spinal curvature, or any other deformity. 
In some persons the size of the right side at the middle and lower por- 
tions is obviously somewhat greater than tiiat of the left. Generally, 
however, to determine the disparity which exists in this region, men- 
suration is requisite. Tlf liiection of the ribs on the right side is a 
little less oblique :i:l :z :_: ':f: side. M. Woillex* found, of 197 
subjects in good hc:^:z. ^:ii 7ri:i_:_: spinal curvature that in 47 only 
was the symmetry in all respects absolutely perfecL A projection of 
the left side in frt)nt, either at, or above, or below the nipple, existed 
in the proportion of 26 per cent. An anterior projection on the right 

*Op.<at. 



INSPECTION. 297 

!i ■ 

We existed only in two instances. Hence, if a projection be observed 
on the rigbt side, the probabilities of its being pathological are much 
greater than if it be on the left side. On the other hand, a posterior 
projection on the right side is very frequently observed, existing in 
29 per cent, of the subjects examined by M. Woillez, while it is very 
rarely noticed on the left side. Variations, due to slight spinal cur- 
vature, are exceedingly common. The majority of persons, especially 
laborers and mechanics, are not altogether exempt from disturbance 
of symmetry due to this cause. The inclination is commonly to the 
right, causing depression of the shoulder, and approximation of the 
ribs on that side. Slight curvature of the spine is also very common 
with females. Want of harmony between the two sides, not suffi- 
ciently marked to be observed without careful examination, may occa- 
sion an appreciable disparity as respects the signs furnished by 
percussion and auscultation, and, hence, the importance of first com- 
paring closely by inspection wherever it is important to institute a 
close comparison by means of the other methods of exploration. It 
is especially with reference to the diagnosis, in certain cases of tuber- 
culous disease, that slight deviations from symmetry, dependent on 
spinal curvature, or other causes, irrespective of existing disease, are 
to be taken into account. Alterations of size and configuration, when 
well marked, will, of course, not require for their discovery a close 
inspection. In such instances, the questions to be determined are, 
whether they are due to deformity, congenital or acquired, or injury 
of the thoracic walls ; to intra-thoracic affections of an anterior date, 
more or less remote, which have left permanent efi'ects on the con- 
formation of the chest, or to present disease. The nature of the 
alterations, and the attendant circumstances, generally render it easy 
to decide in which of these categories abnormal appearances properly 
belong. 

The morbid appearances determined by inspection, which relate to 
present or pre-existing intra-thoracic disease, may be divided into 
those pertaining, jirst^ to alterations of size and form, and second, to 
the respiratory movements. 

1. Morbid Appearances pertaining to the Size and Form of 
THE Chest. — The more important of these may be classified under two 
heads, viz., enlargement and contraction ; each admitting of subdivision 
into general and partial. The enlargement or contraction is general 
when the dimensions of the whole of at least one side of the chest is 
either increased or diminished. Partial enlargement or contraction is 



298 PHYSICAL EXPLORATION OF THE CHEST. 



when there is either a projection or depression of a portion of thCj 
chest on one or both sides. | 

General enlargement of the chest occurs 1st, in consequence of aug*- 
mented volume of the pulmonary organs, or 2d, from the accumula^ 
tion of liquid, or air, or both, within the pleural sac. The enlarge- 
ment from either of these causes, produces changes in the relations 
of the component parts of the chest analogous to those incident to a p 
deep inspiration. The sternum and clavicles are elevated ; the upper j^ 
ribs converge ; the lower ribs are more widely separated ; and the 
abdominal space below the xiphoid cartilage, and between the false 
and floating ribs, is widened. It is generally practicable to determine 
by the appearances pertaining to the enlargement, on which of the \ 
two anatomical conditions just mentioned it is dependent, that is^ 
whether it be owing to the augmented volume of the lung, or to the | 
presence of liquid or air between the pleural surfaces. j 

The lungs are rendered abnormally voluminous by the retention of ' 
an undue quantity of air within the pulmonary cells, constituting 
emphysema. If both lungs are emphysematous, the chest remains 
expanded as it is by a deep inspiration. The enlargement, however, 
is usually most marked at the superior and middle portions of the 
chest ; the reverse of this, as will be seen presently, obtaining when 
the enlargement is due to liquid in the cavity of the pleura. The 
reasons for the fact just stated are, first, emphysema affects most the 
upper lobe ; and, second, the action of the diaphragm incident to the 
labored respiration occasioned by the disease, ofi"ers an obstacle to the 
enlargement of the inferior portion of the chest. The latter, indeed, 
may appear to be contracted, from the greater relative dilatation of the 
superior and middle portions. It is rarely the case, when the en- 
largement from emphysema is general, ^. e. affecting more or less one 
chest at least, that the side is regularly dilated. The emphysema being 
usually more marked at some parts of the lung than at others, the 
surface of the chest presents a corresponding inequality. In this 
respect the enlargement from emphysema differs frOm that due to 
liquid in the pleural sac, the expansion in the latter being more re- 
gular. Moreover, the enlargement from emphysema is never so great 
as that not infrequently observed from pleural effusion. If the em- 
physema affect both lungs, the two sides of the chest will of course 
be enlarged. And if both lungs are equally augmented, it is diffi- 
cult to determine to what extent the dimensions are increased, not 
having the advantage of a comparison of the two sides with respect 



INSPECTION. 299 

to this point. It is, however, very rarely the case that emphysema 
does not affect one lung to a greater extent than the other; and 
observations show that the left lung is more prone to a greater rela- 
tive amount of augmentation than the right."^ Dilatation of the chest 
from emphysema is oftener limited than general, so that the anato- 

imical condition constituting this affection will presently be cited as a 
cause of partial enlargement. General, but usually unequal en- 
largement of the chest, occurs in some cases of bronchitis, probably 
owing to dilatation of the air-cells, in fact to a temporary emphyse- 
matous condition. This obtains especially in bronchitis affecting the 
smaller bronchial tubes (capillary bronchitis) ; and it has been ob- 
served, in a marked degree, in the bronchitis complicating typhoid 
fever.^ Supplementarily, the dimensions of the chest on one side 
become increased, when, from any cause, the functions of the lung 
on the other side are interrupted. Thus, a manifest enlargement of 
the healthy side occurs in chronic pleurisy, owing to the respiratory 
movements, and consequent inflation of the lung on that side, being 
increased to compensate for the partial or complete suspension of 
haematosis in the diseased side. Increased voluntary respiratory 

i efforts systematically continued, effect a considerable augmentation of 
the volume of the lungs, as shown by the enlargement of the chest 

! which follows the use of the tubes of late years in vogue for that 

I purpose. Gymnastic, or other muscular exercise, involving an un- 
usual activity of respiration, also produce the same result. 

In simple pneumonitis affecting an entire lung, the chest on the 
affected side may be visibly enlarged. Generally, however, in cases 
of this disease, the inflammation being limited to a single lobe, the 
enlargement, if it be sufficient to be apparent, is confined to a portion 
of the chest. The augmented volume of the lung incident to this 
affection, is due not necessarily to pleural effusion, but to the deposit 
of solid matter within the air-cells, in consequence of which the 
volume of the lung is sensibly augmented. 

It is in cases in which a large quantity of liquid, or air, or both, 
are contained in the pleural sac, that general enlargement of the 

1 chest occurs most frequently, and is most marked. Universal, and 
not infrequently great dilatation on one side, is an important physical 
sign in chronic pleurisy with abundant effusion, and in pneumo-hydro- 



1 Racle. Op. cit. 

2 Trait6 de Diagnostic Medical, par le Dr. Racle. 1854. 



300 PHYSICAL EXPLO RATIO X OF THE CHEST. 

thorax. General enlargement in these affections is always confined ! 
to one side. An accumulation of liquid, or air, in both pleural cavi- 
ties, sufficient to dilate the two sides, would be incompatible with life^, | 
since it would involve diminution of the volume of the lungs to an * 
extent to render them nearly or quite useless. The enlargement is 
more regular than in cases of emphysema, but it is most manifest at 
the lower part of the chest, in this respect presenting a contrast with 
the enlargement from emphysema. The concomitant signs, however, 
especially in simple pleurisy, render the discrimination sufficiently 
easy. In emphysema, the percussion-resonance is never lost, and is 
generally abnormally clear, with a quality more or less approximating 
to the tympanitic. In pleurisy, with abundant liquid effusion, the 
percussion-sound is flat. In pneumo-hydrothorax, the difference, as 
regards the signs furnished by percussion, is less striking. The 
chest is highly resonant and tympanitic above the level of the liquid, 
flatness existing below that point ; but ^\-ith the aid of the ausculta- 
tory signs, viz., metallic tinkling and amphoric respiration, in connec- 
tion with the symptoms and history, the differential diagnosis does 
not involve much difficulty. The expansion of the thoracic walls, if 
it be considerable, by the du'ect pressure of liquid or air, occasions 
other changes than those incident to simple enlargement, which have 
been mentioned. The direction of the lower ribs undergoes a change. 
They are less oblique. The intercostal depressions are effaced, and 
the integument between the ribs may even become protuberant. It 
has been asserted that the effect on the intercostal spaces is charac- 
teristic of enlargement from the pressure of liquid or gas, in distinc- 
tion from that due to the augmented volume of the lung.^ The inter- 
costal depressions, however, may be effaced in cases of emphysema. 
The error of supposing otherwise, has perhaps arisen from observa- 
tions having been confined to the lower part of the chest, where the 
depressions are most conspicuous in health. Liquid effusion oblite- 
rates the depressions in this situation, the distension being, as has 
been seen, greatest at the lower part of the chest ; but emphysema, 
affecting most the superior portion of the lung, the depressions at the 
lower part may continue, and, if the respiration be labored, may even 
be greater with the inspiratory act than in health, notwithstanding 
the general enlargement of the chest. But it is undoubtedly true, 
that, at the superior portion of the chest, the intercostal depressions, 
in persons in whom they are normally visible in these situations, may 

1 Dr. Stokes. 



' INSPECTION. 301 

be diminislied or lost in consequence of tlie pressure of emphysema- 

'. tous lung. 

Partial enlargement is incident to most of the anatomical conditions 
already mentioned, viz., to emphysema, pleuritic effusion, pneumo- 
hydrothorax, and pneumonitis, and to other affections not adequate 
to give rise to dilatation of the whole of one or both sides of the chest. 

: The enlargement from emphysema is oftener partial than general. 

! It occasions undue prominence over a portion of the chest corre- 

] spending to the seat of the affection, and proportionate in amount to 
the extent of the affection, with diminution or obliteration of the 
intercostal depressions. Affecting the superior portion of the lung 
on one, or more commonly on both sides, but greater on one side than 
on the other, a characteristic appearance is an abnormal bulging 
above and below the clavicle. These appearances, more marked on 
one side than on the other, disconnected from other signs, might lead 
the observer to attribute the relative depression of the supra and 
infra-clavicular regions on one side to disease of the subjacent lung. 
The evidence derived from percussion and auscultation suffice to 
correct this error. The physical evidences of the morbid conditions 
inducing abnormal depression will be wanting, while the concomitant 
sign of emphysema, viz., vesiculo-tympanitic resonance and feeble 
respiration, are found on the side on which the greater prominence 
exists. Over the mammary region the emphysematous lung causes 
greater relative fulness, especially near the sternum, with diminished 
obliquity of the ribs, the intercostal spaces being concealed by the 
pectoral muscle and the mammary gland ; and if the affection exist on 
both sides, the chest presents an unnatural rounded or globular 
appearance, which is highly characteristic. 

In pleuritis with effusion the lower portion of the thorax yields to 
the distension from the fluid gravitating to the bottom of the pleural 
sac, before the superior part of the chest becomes obviously enlarged 
from the accumulation of the liquid. Unless the quantity of effusion 
is large, the dilatation is partial, and situated inferiorly, in this re- 
spect contrasting with enlargement from emphysema in the majority 
of cases of the latter affection. The contrast as respects the signs 
derived from percussion and auscultation, however, generally serve 
to distinguish these affections from each other as broadly as possible. 
In pneumo-hydrothorax the quantity of liquid at the bottom of 
the chest may be sufficient to occasion manifest enlargement when no 
obvious disparity exists above. 



302 PHYSICAL EXPLORATION OF THE CHEST. ! 

I 

Pneumonitis affecting a single lobe sometimes gives rise to an | 
appreciably increased fulness of the part of the chest situated over 
the solidified lung, but the enlargement is apparent in only a small 
proportion of instances. 

Various conditions additional to these may produce partial enlargelii 
ment, the more important of which are as follows : I 

(1.) Circumscribed pleurisy, a collection of liquid sufiicient to occa- 
sion bulging, being confined within a limited area by adhesions of the 
surrounding pleural surfaces. Cases of this description are some- 
times observed, but they are rare. I have met with an instance of a 
large collection of purulent fluid confined to a space five or six inches 
in width extending around the entire semicircumference of the lower 
part of the chest, firm adhesions preventing an ascent of the liquid 
above this space.-^ (2.) Enlargement of the spleen. Marked projec- 
tion of the lower portion of the left side is sometimes due to this ana- 
tomical condition, which occurs especially in protracted or frequently 
renewed attacks of intermittent fever. (3.) Distension of the stomach 
with gas, if considerable, occasions temporarily an abnormal protru- 
sion of the lower left ribs. (4.) Enlargement of the liver, from tumors, 
abscess, or hypertrophy. In this case, of course, the partial enlarge- 
ment of the chest will be situated on the right side. (5.) Liquid 
effusion within the pericardium, and enlargement of the heart. The 
prsecordial portion of the chest may be rendered abnormally promi- 
nent by these affections. It is a curious fact that a projection in this 
situation in health was found by M. Woillez to exist in a larger ratio 
of instances than by Bouillaud in cases of hypertrophy of the heart. 
It is probable that the deviation from symmetry in this situation 
which is found in the proportion of about one-fourth of healthy 
persons, has been often incorrectly attributed to the hypertrophy of 
the heart in the instances in which it has been observed in connec- 
tion with that affection. (6.) Aneurismal and other intra-thoracic 
tumors. (7.) According to Dr. Chambers, deposit of tubercle may 
occasion bulging at the summit of the chest above and below the 
clavicle. This, however, has not been noticed by others, and the 
correctness of the observation needs confirmation. 

Variations in size and form, the reverse of those just considered, may 
also, as has been stated, be general or partial. When contraction is 
general, ^. e. affecting one or both sides, the relations of the component 
parts of the chest are analogous to those incident to a forced expiration. 

• Essay on Chronic Pleurisy, by Author. 



INSPECTION. 303 

^!The upper ribs are more widely separated, while the lower are ap- 
'iproximated to each other, and the space below the xiphoid and between 
jthe lower costal cartilages is diminished. 

General contraction of one side is presented in a striking degree 

.after recovery from chronic pleurisy. The chest is diminished in all 

|its diameters, and so appears in whatever direction it be examined. 

The lung, after remaining collapsed and compressed for weeks and 

months, does not readily assume, after the liquid is absorbed, its 

Ijformer volume. Moreover, the false membranes formed upon its 

-surface, and the union of the pleural surfaces, offer a mechanical 

I jobstacle to its complete expansion. The atmospheric pressure, there- 

I'fore, forces the thoracic walls to accommodate themselves to the 

jdiminished bulk of the pulmonary organ; the reduced dimensions 

:|Compared with the other side (the latter becoming increased in size) 

;|!are su^ciently obvious on inspection, but the altered relations of dif- 

I liferent parts, component and accessory, pertaining to the chest, are 

'jalso -conspicuous. The shoulder is depressed. The inferior angle of 

jjthe scapula falls below the level of that on the unaffected side, and 

projects from the chest. The width of the lower interscapular space 

liis notably diminished. The ribs are approximated. The nipple on 

|the affected side is lowered. More or less spinal curvature takes 

jplace, the lateral inclination being toward the affected side. All these 

I appearances give a characteristic aspect, by which the fact that 

ipleurisy, with copious effusion and enlargement of the chest, has 

existed, is evident at a glance. 

Abnormal diminution of the volume of the lung from any cause, pro- 
vided the pleural cavity does not contain liquid effusion or air, is of ne- 
cessity accompanied by a contraction of the chest exactly proportioned 
to the extent to which the pulmonary organ is reduced in bulk. Col- 
lapse, from obstruction of one of the main bronchi, involves an amount 
of general contraction corresponding to the diminished volume of the 
lung. Condensation from inflammatory exudation within the air-vesi- 
cles, remaining after the removal of this exudation, leads to some re- 
duction of bulk, and hence contraction is sometimes observed to follow 
the resolution of simple pneumonitis, and is general if the inflamma- 
tion and solidification affected the entire lung. The contraction 
under these circumstances is rarely marked, unless abundant liquid 
effusion has coexisted. Slight general contraction has also been 
observed to accompany atrophy of the pulmonary parenchyma in 
connection with dilated bronchial tubes. Extensive tuberculous dis- 



304 PHYSICAL EXPLORATION OF THE CHEST. 

ease induces a shrinking of the lungs, and a corresponding diminu- 
tion of the size of the chest ; and this effect follows long confinement 
to the bed with any disease.^ 

The morbid conditions which, oftener than any other, give rise to 
partial contraction of the chest, are incident to tuberculous disease. 
Abnormal depression above and below the clavicle, and more or less 
flattening at the summit, are occasionally observed in phthisis, and in 
some instances are among the striking physical evidences of that 
disease. These appearances may be presented early in the disease, 
showing that the apex of the lung becomes in some instances reduced 
in volume in consequence of the presence of crude tuberculous matter ; 
but they are found more frequently, and in a more marked degree 
after softening and excavation have taken place. In connection 
with the changes by which cavities are formed, their rationale is suffi- 
ciently plain, since there occurs an actual loss of pulmonary sul^tance 
to a greater or less extent. It is needless to add, that to constitute a 
physical sign of disease the contraction must be manifested on one 
side of the chest by a comparison with the other side. 

Other conditions inducing partial contraction, less frequent, and 
clinically less important, are the absorption of liquid effusion retained 
by pleuritic adhesions within a circumscribed space ; removal of the 
exudation-matter deposited in pneumonitis when the latter is confined 
to a single lobe, and limited collapse or atrophy. 

2. Morbid Appearances pertaining to the Respiratory 
Movements. — The respiratory movements in health have been con- 
sidered in the introduction to this work, inclusive of certain modifi- 
cations incident to sex, age, etc., and also variations, irrespective of 
disease, presented in different individuals, all of which are important 
by way of preparing the observer to estimate correctly morbid ap- 
pearances. Incidentally, in connection with the physiological facts 
relating to this subject, allusion has already been made to the more 
prominent of those aberrations of the respiratory movements which 
constitute physical signs of disease. 

Abnormal frequency of the respiration may be ascertained by 
inspection. By observing the visible motions of the chest or abdo- 
men, the inspirations are enumerated, and the number in a given 
time determined. For this end, it is not necessary that the chest be 
exposed. Diminished frequency of the respiration implies a morbid 

'Vide Sibson's Medical Anatomy, FascicvUus 1. 



INSPECTION. 305 

condition seated in the nervous system, the respiratory function being 
affected secondarily, or symptomatically. Increased frequency is 
incident to various affections compromising the function of hoematosis, 
such as pleurisy, pneumonitis, phthisis, and in a notable degree to 
capillary bronchitis. The number may be increased from the healthy 
average, ranging between 14 and 20 per minute, to 40, 50, and 
even 60. Abnormal frequency of the respirations does not neces- 
sarily denote disease of the pulmonary organs. It is incident to 
disorders affecting the circulation, and to hysteria. In tracing it to 
its source, a point of some utility is the ratio which should exist 
between the respirations and the pulse. As a general rule, four 
strokes of the heart take place in health during the time occupied 
by each respiration. This ratio is usually preserved in diseases 
not involving the heart or lungs. A pulmonary affection may be 
presumed to exist whenever an increase in the number of respira- 
tions is unattended by a corresponding increase in the frequency of 
the pulse. This may be stated as a maxim which will generally hold 
good ; but, of course, the existence of pulmonary disease is to be 
determined in all cases by evidence more direct and positive. 

The rhythm of the respiratory movements is affected differently in 
connection with different morbid conditions. The inspiratory move- 
ment is somewhat shortened, as a general rule, whenever dyspnoea 
exists, the want of fresh supplies of atmospheric air instinctively 
causing the act to be hurried. Shortened inspiration is especially 
marked in emphysema for another reason, viz., the chest is already 
dilated, and the extent of its capability of expansion proportionally 
lessened ; hence it is more quickly performed. This occurs in cases 
in which pain is produced by a full or deep inspiration, as in pleurisy 
or pleurodynia. The patient instinctively represses the inspiratory 
movements, and thus, as far as possible, consistently with the intro- 
duction of suflicient air for haematosis, shortens the duration of inspira- 
tion. An abrupt arrest of inspiration, with manifestations of acute pain, 
is a sign highly distinctive of the affections just named. The inspira- 
tion is also shortened by an obstruction in the larynx, which arrests 
the current of air before the act is completed. This occurs in oedema 
glottidis, in croup, and in spasm of the glottis. On the other hand, 
the expiration is prolonged in emphysema, owing to the impaired con- 
tractility of the lung ; in bronchitis attended with obstruction of the 
smaller bronchial tubes ; and in spasm of the muscular fibres entering 
into the bronchise, constituting nervous asthma. The prolongation is 

20 



306 



great idieii the three marMd conditioiis just mentioned are eamhined, 
whidi is not xmfrefraeiiLlT Ihe case. Under these dreDmstanoes, the 

diffieidfj in t'lr :t : ::_:ince of expirafion is especially manifest at 
tiie dose of t'l r : - Zi~ : : :5 expelled firom the Inngs with a slow- 
ness whidi El : T — 1 : _ r > :* U completed. Ohstruction seated 
in tiie laijn^ : _ 5 ^ r!. or hronehi, is also attended 

by prolonged ex;: :^ I _ 1 stances the doirness with 

nhich the air is ~ : : i_ :-^::igh the expiratory act, in 

this respect fr: __ : 1: _t 1 i?es in irhich the ohatmction 



arises from ^ 
smaller bron: _ 
point of distir. 

To deteriL:: 
the inspirati*: i 
heating time : 
nvmher of I - 

An ohstm: 
sages, prciren: 
oeea^ons cer : 
nith the act : : 
the mspiratc r ^ 
air, the press 
oertam^ pcnnts 
and helow tL^ 
laterally oTer : 
effect, re^ : : 1 
will he El ^ 
tion- I: 
porlion : : _ t 
ment exi t 1 

the ing r-- 

eontraet r t z 

Owmr t : :_r 

nardlj.^ Ai. 
-vlie!:. :::i: :': 
yidti:i_- 7i ' 
pte&>s ;;._ : : : _ 



TTHction seated in the 

; ■■!:? show this to be a 



relative 



lof 
ed: 

:he 



Qh act. 

It TarynXj tr 

^'irSS of sir 



■ -, :: :i:si: pas- 

:-:::^-:- y-ins, 
: : rnts 

' - -^1t i::::n of 
: -7 : "iiission of 
— :'r- :tSs:jii at 
^ ': jTe 
:. ._: .. - .T-rro- 
.7 ~:-i -_ ThB 

-.-.z ::i = :iiaiion, 
T.'iii .:; obstme- 
slight. the lower 

; :ii:-^5:::z moTe- 



;:::::! :: -: ::.-y-- ^--n-lmg 

: -7 = , :^T tI'-. - "J.:. : ::: ~^i- are 

-:_::i :- :■■;;:;.::,__ - led. 

::^. :i7 i;,:-: ::, r.:. 1: : "- '. :iit- 

;- ;i :Lt :i:s: ;i;: r:i:7;i. ;::>irs 

_es hare become rigid and im- 

1 7 :!ioracic walls, resisting the 

_ :iie abdomen retracts with 

^tion on idie tiunracie moyements is 



zihid. 



INSPECTION. 307 

especially marked in children, owing to the greater flexibility of the 
thoracic walls in early life. Continued obstruction in this way leads 
to permanent contraction and deformity of the chest. 

In treating of the respiratory movements in health, it has been 
seen that they may be divided into different types, viz., abdominal, 
and costal ; the latter being farther divisible into the superior and 
the inferior costal type. The combination of these several types, and 
their relative predominance, respectively, in other words, different 
modes of breathing, constitute, as already stated, important physical 
evidence of disease. In breathing voluntarily forced, or in laborious 
respiration from any morbid cause, all three types, viz., abdominal, 
inferior costal, and superior costal, are exemplified, but especially the 
two latter become prominent, compared with the habitual tranquil 
breathing in the male, which involves chiefly, and sometimes almost 
exclusively, the abdominal type. In cases of peritonitis, in which 
the play of the diaphragm occasions acute pain, the respiratory move- 
ments are in a great measure restricted to the thoracic walls : the 
breathing is costal. The same effect is produced by mechanical ob- 
struction to the descent of the diaphragm from ascites, pregnancy, 
tympanitis, or abdominal tumors. On the other hand, in cases of 
pleuritis, or pleurodynia, in which the thoracic movements occasion 
acute pain, these movements being instinctively restrained, the ab- 
dominal are proportionately increased, and the breathing is said to be 
abdominal or diaphragmatic. In a case of double pleurisy, which 
came under my observation, in which the chest on both sides was half 
filled with liquid effusion, the lungs firmly adherent above the level 
of the fluid, the type of breathing was almost exclusively superior 

I costal. The respiratory movements at the summit of the chest were 
remarkable. It is a repetition to state that the superior costal type 
of breathing, in health, is exemplified much more in the female than 
in the male. In paralysis affecting the costal muscles, the abdominal 
type of respiration becomes strongly marked. 

Disparity between the two sides of the chest, as respects the respi- 
ratory movements, constitutes, in some instances, important diagnos- 

j tic evidence of disease. In the dilatation of the chest on one side from 

( large liquid effusion, the movements on that side are notably dimi- 
nished, and may be almost null, whilst, on the opposite side, they are 

I supplementarily increased. A similar disparity, but never to the 
same extent, exists in some cases of emphysema, in which the affec- 

\ tion is either confined to, or is more marked, on one side. The same 



PHYSICAL EXPLORATION OF THE CHEST. 

contrast exists in pneumo-liydrothorax. In simple pneumonia, affect- 
ing either the upper or lower lobes, the respiratory movements, in a 
certain proportion of cases, are obviously restrained ; and this is to be 
observed after acute pain has ceased, or in cases in which that symp- 
tom is not present. This was denied by Laennec ; but a careful com- 
parison of the two sides, in a series of cases, must convince any one 
of the correctness of the statement.^ A local disparity at the summit 
of the chest is sometimes a highly significant sign of tuberculous dis- 
ease. The superior costal movements, owing to pleuritic adhesions, 
or other causes, in some instances, are notably less on the side in 
which a tuberculous deposit exists, than on the opposite side. This 
will be more manifest if the respiration be labored, so as to call into 
action the superior costal type of breathing. It may be obvious if 
the respiration be forced, when it is not apparent with tranquil 
breathing. It will be more marked in females than in males, owing 
to the superior costal type being more prominent in them than in 
males, irrespective of disease. An inspection of the chest, with 
reference to a careful comparison of the relative mobility of the 
two sides at the summit, is a point not to be omitted in an ex- 
ploration for evidence for or against the existence of tuberculous 
disease. The diagnostic value of this sign of course depends on the 
assumption of equality in the movements of the summit of the chest 
in health. As the rule, provided the two sides be symmetrical in 
conformation, this may be assumed ; but in making examinations of 
persons presumed to be free from disease, I have, in a few instances, 
observed a slight disparity in that situation, as well as at the lower 
part of the chest. In view of these occasional exceptions to the 
general rule, a disparity in mobility, as an isolated sign, should be 
distrusted ; but, associated with other signs, it is entitled to consider- 
able weight. Finally, a marked disparity in the movements of the 
two sides obtains in cases of hemiplegia. 



Summary. 

The phenomena determined by inspection embrace morbid appear- 
ances pertaining, (1), to the size and form of the chest ; and, (2), to 

^ Laennec, it is to be remarked, paid very little attention to the physical signs derived 
from inspection. Indeed, he declared that the ocular examination of the chest during 
respiration is of very little utility. 



INSPECTION. 309 

the respiratory movements. The morbid appearances pertaining to 
size and form are resolvable, for the most part, into enlargement and 
contraction, both of which may be general, i. e. extending over the 
chest at least on one side ; or partial, i, e. limited to a portion of the 
chest on one or both sides. 

General enlargement involves either augmented volume of the lung 
on one or both sides ; or the presence of liquid or air in the pleural 
J cavity. To the former of these anatomical conditions is due the en- 
;.| largementj in cases of emphysema, which may affect both sides of the 
; chest. Enlargement of the chest from emphysema is most marked 
^1 at the superior and middle portions of the chest ; and the surface 
V rarely presents a uniform regular dilatation. General enlargement 
I on both sides is observed in some cases of bronchitis. A more fre- 
\. quent anatomical condition, giving rise to general enlargement, is the 
,: accumulation of liquid in the pleural sac in cases of chronic pleurisy. 
j| General enlargement from this cause is necessarily confined to one 
fl side. The dilatation, from the pressure of liquid, is more uniform, 
;i and the surface of the chest presents a more regular appearance. 
. The intercostal depressions are effaced, in chronic pleurisy, where they 
f are normally most conspicuous, viz., the anterior and lateral portions 
<! at the lower part of the chest. In this situation they are rarely 
ji effaced by the pressure of an emphysematous lung so as not to be marked 
I with inspiration ; but they may be diminished or lost over the superior 
)' portions in cases in which they are normally apparent in that situa- 
tion. General enlargement of the chest may also proceed from 
,j pneumo-hydrothorax, and, in a slight degree, from simple pneumo- 
,1 nitis affecting an entire lung. Partial enlargement, oftener than 
;j general, is incident to emphysema, pleurisy, pneumo-hydrothorax, 
and pneumonitis. It is also incident to circumscribed collections of 
liquid ; enlargement of the spleen ; distension of the stomach ; aug- 
mented size of the liver ; pericarditis with effusion and hypertrophy of 
the heart ; aneurismal and other intra-thoracic tumors. 

General contraction of the chest is especially marked after reco- 
very from chronic pleurisy. It results from collapse of lung following 
obstruction of the bronchus leading to it ; and accompanies in a slight 
degree the diminished volume succeeding pneumonitis affecting an 
entire lung, and also coexists with dilated bronchial tubes. Partial 
contraction above and below the clavicle is sometimes marked in 
cases of phthisis, being incident to the early stage, in some instances, 
but more frequent and more marked in an advanced period of the 



310 PHYSICAL EXPLO RATION OP THE CHEST. 

disease. It follows the removal of pleural effusion, attends limited 
collapse, and the reduction in the volume of the lung succeeding 
pneumonitis. 

Increased frequency of the respirations is incident to affections 
compromising the function of hsematosis, and is therefore observed in 
pleui'isy, pneumonitis, phthisis, and especially in capillary bronchitis. 
Occurring oftener than in the ratio of one to four beats of the heart, 
pulmonary disease of some kind is generally indicated. The inspira- 
tion is shortened, as a general rule, in dyspnoea. It may be arrested 
before the act is completed by an obstruction of the windpipe, and is 
voluntarily arrested in consequence of pain in pleuritis and pleuro- 
dynia. It is short in emphysema, o^ing to the permanent expansion 
of the chest. The expiration is prolonged in emphysema, owing to 
the diminished elasticity of the lung ; and in cases of obstruction in 
the air-passages. If, owing to obstruction in any part of the air- 
passages, the air-cells are not filled proportionably to the enlargement 
of the chest, the act of inspiration causes depression of the thoracic 
walls at certain points, viz., above and below the clavicles, and later- 
ally and anteriorly at the lower part of the chest. This is more 
marked in children than adults, and is one of the causes of deformity 
of the chest. The respiration is abnormally thoracic or costal, when 
the play of the diaphragm is voluntarily restrained in consequence of 
the pain which it occasions in peritonitis, and when its descent is pre- 
vented mechanically in tympanitis and ascites, by tumors, and in 
pregnancy. Abdominal or diaphi'agmatic respii'ation is marked when 
the thoracic movements occasion suffering in pleuritis or plem'odynia, 
and in paralysis of the costal muscles. In health, the type of respi- 
ration in the male is chiefly abdominal, but whenever the breathing is 
labored, the inferior and costal types are also manifested. When the 
chest on one side is greatly dilated in chronic pleurisy, the side 
affected is nearly immovable, the movements on the unaffected side 
being supplementarily increased. The same disparity, but in a less 
degree, is exhibited in cases of emphysema in which the affection is 
limited to or more marked on one side. It is also observed in 
pneumo-hydi'othorax. A disparity in the respiratory movements of 
the summit of the chest is sometimes a valuable sign of tuberculous 
disease. In cases of hemiplegia, the movements of« the chest on the 
paralyzed side of the body are diminished, and those on the opposite 
side increased. 



INSPECTION. 311 



History. 

Inspection was doubtless resorted to, in the investigation of 

diseases, from the earliest date in the history of medicine ; but the 

,. impulse given to the subject of the physical exploration of the chest 

I by the discovery and researches of Laennec, has led practitioners to 

IJ employ, to a much greater extent than previously, and with vastly 

I more advantage, this method of examination. The value of results 

I obtained by inspection is very greatly enhanced by their association 

with the phenomena furnished by other methods, more especially by 

percussion and auscultation. 



CHAPTER Y. 

MENSURATION. 

In tlie physical exploration of the chest, it is sometimes useful to 
ascertain the extent of abnormal alterations, as respects size and of 
respiratory movements, with greater accuracy than can he determined 
by the eye. For this end, measurements are resorted to. These 
constitute a distinct method of examination, called mensuration. For 
ordinary clinical purposes, in other words, with reference to diagnosis, \ 
the practical value of this method is very limited. It is rarely im- |fi 
portant, because the information obtained by inspection is sufficiently 
exact, and in some instances, even more satisfactory. The two ob- 
jects for which mensuration is employed, viz., to determine abnormal 
alterations in size, and in the extent of respu-atory movements, are 
quite distinct, and require separate notice. 

1. Mensuration with referexce to abnormal alterations 
IN SIZE. — Measurements with reference to alterations in size may be 
made in different modes. The diametrical distance between opposite 
points may be determined by means of compasses, constructed for 
that purpose, called callipers. For example, the antero-posterior 
diameter of each side, in different situations, is ascertained by plant- 
ing the extremities of the two blades of the instrument in front and 
behind, successively, on corresponding points on the two sides, and 
noting the extent of the separation of the blades as indicated on a 
graduated scale connected with the instrument. A comparison of the 
relative size of the two sides at any situation, with due care, may in 
this way be instituted. If, however, certain precautions are not 
carefully observed, such as placing the extremities of the instrument 
on exactly corresponding points in the examination of the two sides, 
and being cautious not to make greater pressure on one side than on 
the other, the results will be likely to be fallacious ; and in view of 
this liability, it may be doubted whether partial enlargements or con- 
tractions on one side are not generally more satisfactorily appreciated 
by comparison with the eye. I have had no practical experience in 



MENSURATION. 313 

the use of callipers, and so far as my knowledge extends, they are 
i rarely made use of even by those who devote special attention to 
I physical exploration. A difference between the two sides in any of 
the diameters, sufficient to become an important physical sign, is ap- 
j parent on careful examination and comparison by inspection. It is 
I chiefly in noting facts for analytical investigation, that an exactness 
of measurement in this or other modes, which can be expressed nu- 
I merically, is desirable. For examinations with a view simply to 
j diagnosis, it is not requisite ; and this being the case, the objections 
to the use of an instrument, cumbrous and somewhat formidable in 
: appearance, have justly precluded its introduction into private prac- 
tice. The variations in size obtained by this mode of measurement 
I are those already noticed under the head of Inspection, viz., on the one 
I hand, enlargement, general and partial, due to emphysema, pleuritic 
' effusion, etc. ; and, on the other hand, contraction, incident to re- 
covery from pleurisy, tuberculosis, etc. 

I Another application of mensuration consists in measuring distances 
i on the surface of the chest, between certain prominent anatomical 
: points. For example, the nipples, in a chest perfectly symmetrical, 
of an adult male, are situated on the fourth rib, or interspace, equi- 
i distant from the centre of the sternum. Enlargement of one side in 
I connection with morbid conditions which have been already men- 
! tioned, removes the nipple on the affected side to a greater distance 
1 from the mesial line, at the same time raising it above the level of 
!; the other. Contraction of the chest, on the other hand, diminishes 
the distance, and depresses it below its natural situation. The extent 
of these changes may be accurately measured. The distance from 
the posterior margin of the scapula to the spinal column is increased 
when the chest is dilated, and diminished when the chest is con- 
tracted. In the first instance, the inferior angle of the scapula is 
observed to be elevated above the level of that on the unaffected side ; 
and, in the second instance, to be lowered. These deviations from 
symmetry incident to disease, may be accurately ascertained by compa- 
rative measurements. The extent to which the ribs are separated or 
I approximated by different morbid conditions may also be measured. 
I In recording cases, it is well to express the amount of disparity be- 
i tween the two sides, as respects the points just mentioned, in figures ; 
^1 but so far as concerns the bearing of the facts on diagnosis, such pre- 
cision is superfluous. The facts, as estimated by the eye, are suffi- 
ciently exact. 



314 - PHYSICAL EXPLORATION OF THE CHEST. 

Another mode of practising mensuration, consists in measuring 
the horizontal circumference of the chest, and comparing the two 
sides in this respect. This may be done without difficulty, by means 
of a common tape or cord, with the aid of an assistant, if the patient 
be able to be raised to a sitting posture. The cord or tape is passed - 
around the chest just below the scapula, one end being accurately fixed . 
to the mesial line over the sternum in front. After being evenlj 'jj 
adjusted with equal pressure on both sides, taking pains to see that the 
direction is as circular as possible, an assistant marks the point at which 
it crosses the spinous process of the vertebras with ink, or by insert* ^ 
ing a pin. The point meeting the extremity fixed at the centre of 
the sternum is also marked. The data for determining the circmn* 
ference of the whole chest, and that of each side are in this way ob- 
tained ; and since, practically, the chief object is usually to compare 
the two sides, it suffices to double the cord or tape from the point at 
which it crossed the spine, and ascertain how much one portion ex- 
ceeds the other in length. In place of a common cord or tape (which 
answers every purpose if other means are not at hand) a graduated 
measure, such as tailors use, may be employed. The semi-circumfe- 
rence at each side is sometimes measured separately ; but a difficulty 
in the way of accui'acy arises from the liability of the chest not being 
equally expanded while the measurements of the two sides are taken 
in succession. This difficulty may in a great measure be obviated 
by requesting the patient to take a deep inspiration as each side is 
measured, and to hold the breath until the measurement is made. 
A better plan, however, is to use two graduated tapes joined together, 
the scale of inches and fraction of inches commencing on each tape 
at the line of junction. 

One great advantage of this simple plan (attributed by Dr. Walshe 
to Dr. Hare) is, that it may be apj^lied while the patient is recum- 
bent. The point of junction being fixed over the spine, and the two 
tapes brought forward, the circumference of each side is shown by 
a glance at the centre of the sternum. Of the convenience of this 
plan I can speak from my own experience. Comparison of the semi- 
circular measurements of the two sides enables the examiner to form 
an idea of the extent to which the dimensions of one side are either 
increased or diminished by disease ; but the actual difierence of size, 
it is to be borne in mind, does not represent exactly the amount of a 
morbid increase or diminution, since, as a general rule, the two sides are 



MENSURATION. 815 

I normally unequal. In the majority of persons the right semi-circum- 
1 ference exceeds the left, the mean disparity being about half an inch. 
In a small proportion of individuals the two sides are equal, and in a 
ij few instances the left semi- circumference exceeds the right. The 
;! latter is found to occur oftener among left-handed persons. Owing to 
;^:l these natural differences, the fact of a disparity as shown by the results 
1 of mensuration, if it be but small or moderate, does not necessarily 
I denote disease. To become a morbid sign it is to be taken in connec- 
^i tion with other signs, unless the disparity exceed the range of normal 
I variations ; and if this be the case, comparison of the two sides by 
inspection suffices to establish the existence of morbid enlargement 
or contraction. Mensuration under these circumstances only assists 
°| in forming a closer estimate of the extent of the deviation from the 
^1 normal dimensions, a point not without interest, but not essential to 
I diagnosis. Moreover, measurement of the horizontal circumference 
Hjof the chest affords evidence only of general, not of partial enlargement 
■or contraction of one side. Partial projection or depression may 
lli exist without a corresponding increase or diminution of the semi-cir- 
ri cumference of the side affected, and under these circumstances the 
"latter must be determined by inspection, or by the callipers. The 
■advantage of circular measurement does not relate to the determina- 
Ition of the existence of a morbid disparity in size between the two 
Isides, so much as to another object, viz., to ascertain the variations 
'in the amount of morbid increase at different periods in the same 
jcase. This object has reference mainly to a single disease, viz., 
chronic pleurisy, including empyema. Mensuration employed daily, 
or at intervals more or less brief, during the continuance of this 
disease, the result being noted, affords exact information respecting 
the progress in the accumulation or removal of the liquid effusion. 
The practitioner, in other words, is able to determine with precision 
whether the quantity of effusion be increasing or lessening, or sta- 
tionary. Information on these points may also be derived from 
Inspection, but not so promptly and less accurately. The positive or 
■jaegative effects of different therapeutical measures are demonstrated 
n this way by the evidence afforded by mensuration, and in this 
)oint of view measurements repeated more or less frequently are of 
faot a little utility in regulating the treatment. These remarks with 
'^i^eference to pleurisy, are measurably applicable to pneumo-hydro- 
':horax, and to some extent to emphysema. The progress in the 
l^low expansion of the chest after the contraction which immediately 



316 PHYSICAL EXPLORATION OF THE CHEST. 

follows the removal of liquid effusion, may also be determined, from 
time to time, by measurements, with greater precision than by means 
simply of ocular examinations. i 

The foregoing remarks have related to a comparison of the two I 
sides of the chest, by means of which, as has been stated, morbid \ 
alterations in size are usually determined. Abnormal deviations in 
this respect, as in other points, are not ascertained by reference to 
any fixed criterion or average, but the chest on one side is taken ii 
as the healthy standard peculiar to the individual. The variations in 3 
the size of the chest are so great within the limits of health, thatk 
mean dimensions obtained by a series of measurements are of little 
value in estimating the changes due to disease. The horizontal cir- 
cumference of the whole chest, i. e. of both sides, may range, ac- 
cording to Walshe, between twenty-seven and forty-four inches ; the f 
mean, in the adult male, being about thirty-three inches. With such 



en I) 
ofl 



an extensive range between the extremes of healthy limitation, it is 
little value to take into consideration the united dimensions of the two \i 
sides in determining the existence or the nature of disease ; the dis- fj 
parity between the sides is the point to be considered. The researches 5' 
by M. Woillez, however, have led to some interesting results as re- 
spects the changes in the general capacity of the thorax which are to f.^ 
be observed during the career of acute diseases. These results, ex-p! 
pressed as concisely as possible, are as follows :^ 

Examined by mensuration at different stages of the course of dif-l!'! 
ferent acute affections, accompanied by well-marked febrile move-! 
ment, the size of the chest is found to present almost constantly a | 
series of changes. These changes may be arranged in three periods, j 
which follow in regular succession, viz., first, progressive enlarge-! 
ment, next, a stationary period, and lastly, a gradual return to the \ 
normal dimensions. These three periods are of variable duration, f 
corresponding to the varying course and character of different affec- 
tions. These alterations in capacity are accompanied by proportion- 1^ 
ate modifications of the elasticity of the thoracic walls. The elasticity | 
diminishes as the enlargement increases, and again, gradually returns '■^, 
to the normal degree as the chest resumes its natural size. The extent 11 
of enlargement varies from three-fifths of an inch to a little over three r 
inches, the mean increase being about one and a half inches. In thei^ 
exanthematous fevers, the enlargement is shorter in duration than in f 
other acute affections ; and in variola especially, a return to the normal! 

' Traite de diagnostic medical; par Racle. ' 



MENSURATION. 317 

a| size takes place prior to the complete development of the eruption. 

^1 Particular causes, affecting the regular course of any acute affection, 
may disturb the regularity of the succession of the several periods into 
which the alterations of thoracic capacity are divided. The enlarge- 
ment of the chest, and the diminished elasticity, are attributed by M. 

(jl Woillez, to pulmonary congestion accompanying the development 

J and career of acute affections. These changes in the size of the chest, 
revealed by mensuration, he regards as evidence that pulmonary con- 
gestion is an important element of all acute diseases. Mensuration 
enables the practitioner to observe the extent and progress of this 
element. In degree, the enlargement sustains no constant relation 
to the frequency of the pulse ; and it is affected neither by blood- 
letting, nor gastro-intestinal evacuations, nor by any course of alimen- 
tation. The presence of gas in the stomach, in variable quantity, is a 
cause of variation in the size of the chest, not to be overlooked. 
Progressive emaciation is another cause of diminished size by mensu- 
ration, which is to be distinguished from the effect of the reduced 
volume of the pulmonary organs. Occasionally, irregular oscillations 
in the amount of pulmonary congestion appear to occur, giving rise 
i to variations in the thoracic capacity. But, as a general rule, in- 
creasing enlargement of the capacity of the chest denotes a progres- 
sive development of the disease, a stationary condition of enlarge- 
ment indicates a persisting acuteness, and a decrease in the dimen- 
i sions of the chest often precedes the symptoms and other signs which 
afford evidence of commencing resolution of the malady. These con- 
clusions, purporting to have been deduced from a series of measurements 
in a variety of acute affections, are striking, and not unimportant. Of 
their correctness, I am unable to speak from personal observations. 

2. Mensuration with reeerence to abnormal alterations 

IN THE extent OF RESPIRATORY MOVEMENTS. — Measurement of 

the extent of motion, at different portions of the chest, involved in 

l| the respiratory acts, is made by instruments which have been already 

y described. By means of the "chest-measurer," invented by Dr. 

ij Sibson, movements in a diametrical direction may be determined with 

:i great accuracy. A great number of examinations, with the aid of 

jtliis instrument, enabled Dr. Sibson to arrive at interesting and im- 

jportant results respecting the actual and relative extent of the motion 

jof different parts of the chest in health, with the peculiarities incident 

;to sex, age, etc. ; and, also, the effects of different forms of disease, in 

modifying the normal respiratory movements. The more important 



318 PHYSICAL EXPLORATTOX OF THE CHEST. 

of the facts deduced by Dr. Sibson have been already referred to in y 
the introduction to this -work, and under the head of Inspection, in j 
the preceding chapter. Dr. Sibson's ingenious instrument, however, i 
only measures the forward movements of the chest. It does not ; 
show the actual amount of expansive motion. For this end, the 
" Stethometer" of Dr. Quain is preferable. Moreover, the last- [ 
mentioned instrument is less cumbrous, and is applied with much |l 
greater facility. I cannot, however, speak of the merits of either 
from personal experience. Their value chiefly relates to scientific 
researches, in which it is convenient, and indeed important, to express |: 
the results of observations with numerical exactness. For ordinary 
clinical objects, this is not necessary. It suffices to determine the 
existence of certain abnormal modifications, without ascertaining, 
with arithmetical precision, the extent of the deviations from health. 
This information is furnished by inspection. Mensuration, with re- 
ference to the respiratory movements, is even less essential, and less 
resorted to, than with reference to deviations in size. Ocular exami- 
nations, comparing carefully the two sides of the chest, enables the 
observer to distinguish, without difficulty, an amount of abnormal 
alteration in the respiratory movements, sufficient to constitute them 
physical signs of disease. When it is desired to confirm the evidence 
which the eye discovers by resorting to measurement. Dr. Quain's 
stethometer is doubtless applicable and convenient. To measure par- 
tial movements, this, or some analogous instrument is required. But 
to ascertain the amount of expansive movement of both sides, or of 
the two sides separately, in order to institute a comparison between 
the two, it is sufficiently accurate for practical purposes to take the 
circular dimensions with the graduated tape, first, during a full in- 
spiration, and next after a forced expiration. If the circumference of 
the two sides, when fully dilated, and subsequently when contracted, be 
obtained, the simple rule of subtraction gives the range and expansi- 
bility at the part of the chest where the circular measurement was 
made. The expansibility of each side being in the same way ascer- 
tained, a comparison of the two sides, as respects the amount, of 
course gives the extent to which the movements on one side are ab- 
normally diminished, or on the other side increased, or, again, what 
is oftener the case, diminished on one side, and, at the same time, in- 
creased on the other side. The effect of disease on the respiratory 
movements is most strikingly exemplified in cases of chronic pleurisy 
with large effusion. As stated by Walshe, the difference between the 



MENSURATION. 319 

fullest expiration and the fullest inspiration on the side affected, may 
not exceed one-sixteenth of an inch, while the other side, in conse- 
J quence of its movements being supplementarily increased, may show 
a difference of two and a half inches, — an extent as great as the move- 
ments of both sides united, in health. 

The various forms of disease which occasion notable modifications 
of the respiratory movements, have already claimed consideration in 
I connection with the subject of inspection. To consider them in con- 
I nection with mensuration, would involve a repetition of the facts 
J contained in Chapter IV, to which the reader is referred. 

Mensuration may be extended to embrace the measurement of the 
capacity of the chest, as regards the quantity of air which it is capable 
of receiving with inspiration, and expelling by the act of expiration. 
An instrument called the spirometer^ invented by Dr. Hutchinson, 
is designed for this purpose. This instrument has been already no- 
ticed in connection with mensuration of the chest in health ; and in 
that connection, its application to the study of disease was incidentally 
considered. In view of the extensive range of capacity within the 
limits of health, and, also, of the fact, that the quantity of air which 
can be voluntarily expelled from the lungs, is subject to considerable 
variations from causes irrespective of the condition of the pulmonary 
organs, causes affecting muscular power, the utility of the spirometer 
in the diagnosis of disease is very limited. The information which it 
is capable of affording is, for the most part, negative ; that is, if the 
vital capacity, adopting the expression used by Mr. Hutchinson, be 
great, it is presumptive evidence that intra-thoracic disease does not 
exist ; but found below the average, it is by no means proof of the 
existence of pulmonary disease. Even when the existence of disease 
is positively indicated by this mode of mensuration, it furnishes no 
indications of the nature or seat of the morbid condition. If the vital 
capacity of an individual in health have been ascertained, whether it 
be great or small, so long as it continues undiminished, it may be 
rationally inferred that the lungs remain free from disease. With 
reference to such a comparison, it is desirable that persons should 
test the power of expiration in health, and note the result. Repeated 
; trials with the spirometer, also, during the course of disease, will 
afford some evidence as to the extent of its progress ; but this evi- 
dence cannot be much relied upon, owing to the influence of circum- 
stances other than pulmonary lesions. 

The spirometer employed by Dr. Hutchinson is so cumbrous an 



320 PHYSICAL EXPLORATION OF THE CHEST. 

instrument as to be only available in hospital or office practice. Mr. - 
Coxeter, sni-gical instrument maker, in London, has invented a sub- 
stitnte, which is very convenient andjportable. It consists of a bag, 
made of India-rubber cloth, of sufficient size to hold the utmost amount ^ 
of ail' that a person vrith the largest vital capacity can expel from the 
lungs, with two apertures, to one of which is fitted a glass mouth- 
piece, while the other communicates with a cylindrical bag, holding, 
when fully distended, fifty cubic inches of air. The latter is the - 
meter, and by a scale marked on its exterior, any quantity less aS 
the amount it will contain may be measui'ed. The orifices of the 
large bag or reservou' are regulated by stop-cocks ; and by an orifice - 
at the extremity of the meter, also regulated by a stop-cock, its con- 
tents may be expelled. The patient breathing into the reservoir with 
as prolonged an expiration as possible, the au' is retained by closing ,- 
the stop-cocks. It is then measured, by refilling the meter until all ^ 
the contents of the reservoir are expelled. The whole apparatus can 
be folded compactly, and placed in a leathern case, not too bulky to 
carry in the pocket. 



Summary. 



I; 



The objects of mensuration are to determine, fii'st, alterations in the "* 
size of the chest, which may be partial or general ; and, second, alte- 
rations in the extent of respiratory movements. Partial enlargement 
or depression is measm-ed by means of callipers ; general enlargement 
or contraction, is determined by comparing the horizontal semi-cir- 
cumference of the two sides, which is ascertained by the employment 
of a graduated inelastic tape, and by measuring distances between r 
certain anatomical points, such as the distance of the nipple from the i 
mesial line, and the space between the posterior margin of the scapula t 
and the spinal column. In scientific researches involving obserra-i 
tions recorded for analytical investigation, it is convenient and impor- ' 
tant to employ the instruments just mentioned, expressing results in ' 
figures; but, in general, alterations in size may be ascertained suffi-- 
ciently for diagnosis, by inspection. Clinically, the advantage of i 
mensuration with reference to comparison of the dimensions of the ' 
two sides, relates to variations taking place at different periods in the 
same case, these variations sometimes being important to be consi- 
dered in connection with therapeutical agencies ; and, thus restricted 



MENSURATION. 321 

^pleuritis witli effusion is the affection in wMch this method of explo- 

^ration is particularly useful. According to the researches of M. 

jWoillez, mensuration practised daily during the career of acute dis- 

jeases, shows first a progressive enlargement of the whole thorax during 

ithe development of the disease; second, a stationary condition of 

jienlargement while the acute symptoms continue ; and, third, a gradual 

return to the normal size while resolution of the disease is going on. 

This series of alterations is accounted for by M.Woillez on the hypothesis 

of pulmonary congestion existing as an important element of all acute 

j affections. 

,,; Abberrations of the respiratory movements are determined by 
J the chest-measurer, and by the stethometer. The first measures 
j'the extent of motion, at any part of the chest, in the direction of its 
i diameter ; the latter measures the amount of expansive movement. 
j| These instruments, although extremely serviceable in certain scien- 
kific researches, are not needed in determining the existence or non- 
•| existence of abnormal movements, inasmuch as comparison of the 
Il two sides with the eye suffices for that purpose. To institute a com- 
!; parison between the two sides as respects the relative extent of gene- 
; ral expansibility, the difference may be taken between the horizontal 
circumference after a deep inspiration, and that after a forced expi- 
ration : this mode of determining the extent of general motion does 
not secure complete accuracy, but it is sufficiently exact for ordinary 
practical purposes. 

The spirometer invented by Dr. Hutchinson, is designed to deter- 
mine the "vital capacity" of the lungs, by ascertaining the quantity 
of air which can be expelled by a single prolonged expiration ; the 
results of this method of mensuration are, however, in a great mea- 
sure, dependent on circumstances affecting muscular power, irrespec- 
tive of the condition of the pulmonary organs ; and the degree of the 
vital capacity of different individuals is found to differ widely in 
health. 

It is rarely, therefore, that positive information respecting the ex- 
istence of pulmonary disease is to be obtained from this source, in 
cases in which symptoms and other signs fail to indicate the fact. In 
a negative point of view, however, the spirometer may sometimes be 
useful. If the degree of vital capacity be found to equal or exceed 
the average, it warrants the presumption that disease does not exist ; 
or, if the amount of vital capacity proper to an individual in health 

21 



322 PHYSICAL EXPLORATION OF THE CHEST. 

be known, and it be found that tbis amount is not diminisbed, it may 
be fairly presumed tbat tbe pulmonary organs are sound. 



History. 

Tbe remarks made under tbis bead, in connection witb tbe subject 
of Inspection, Cbapter IV, are equally applicable to mensuration. 



CHAPTER YI. 

PALPATION. 

Examination by palpation consists in simply applying the palmar 
surface of the hand or the fingers to the exterior of the chest. This 
is one of the least important of the methods of physical exploration, 
but in some instances it furnishes signs of considerable importance. 
In general, the evidence of disease which it affords is auxiliary to or 
confirmatory of information, more positive and complete, derived from 
other methods. The phenomena appreciable by the application of 
the hand to the chest are of different kinds. I shall proceed at once 
to notice those which are important to be borne in mind with reference 
to the diagnosis of intra-thoracic diseases. 

By means of the touch, the existence of tenderness on pressure, its 
degree, situation, and extent, are ascertained. Manual examination 
assists in determining whether it be seated in the integument, or 
within the thorax. If it be owing to sensitiveness of the surface, it 
will be superficial ; mere contact of the fingers will excite pain, which 
is not proportionately increased if firm pressure be made. If intra- 
thoracic, the hand lightly applied will be supported, and the suffer- 
ing will be according to the force employed. In short, the rules by 
which a neuropathic tenderness is distinguished from that due to 
inflammation, are available here, as in other situations. 

The elasticity of the thoracic walls is ascertained by manual exami- 
nation. Information on this point, it is true, may be obtained, inci- 
dentally, in practising percussion ; but in order that the attention 
shall not be divided between two objects, it is useful to make pressure 
with express reference to the sense of resistance. The elasticity of 
the walls of the chest is diminished in proportion as the pulmonary 
substance is rendered non-elastic by solidification ; and, also, in a 
notable degree, when a considerable quantity of liquid is contained 
within the pleural sac. In connection with other signs, this possesses 
considerable importance. 



324 PHYSICAL EXPLORATIOX OF THE CHEST. 

By passing the hand over the thoracic surface, we are aided in 
judging of the nature and extent of changes in form and size incident 
to disease. Inequalities, due to depressions or projections, are some- 
times better appreciated by the touch than by inspection. By the 
touch, it is ascertained whether enlargement arises from a morbid 
condition exterior to the walls of the chest, for example, oedema, or 
abscess, or whether it be intra-thoracic. If the latter, the sensations 
communicated to the hand sometimes afford important information as' 
to the character of the disease. A circumscribed enlargement, pro- 
duced by an aneurismal tumor, may be accompanied by a pulsation, 
which, in connection with other signs, serves to establish the diag- 
nosis. It is important, however, to remark, that a circumscribed 
pulsating tumor may be caused by a collection of pus beneath the skin, 
communicating with an accumulation within the chest by means of a 
perforation through the thoracic wall. In this case, the pulsation is 
due to the cardiac impulse propagated through the mass of liquid. 
Throbbing, diffused over a considerable extent of surface, has also 
been repeatedly observed in cases of empyema without perforation of 
the thoracic wall, the pus being retained entirely within the pleural 
cavity. These instances have given rise to a variety of the affection 
called " pulsating empyema."^ Under these circumstances, the 
heart's impulse, communicated to the purulent collection, is sufficient 
to cause an appreciable movement of the walls of the chest. The 
same phenomenon has been observed by Dr. Graves, in a case of 
pneumonitis, and by Dr. Stokes, in connection with a large cerebri- 
form tumor, springing from the posterior mediastinum, and dis- 
placing the upper lobe of the left lung.^ In the latter instances, it is 
doubtful whether the pulsation was the transmitted cardiac impulse, 
or whether it was due to arterial thi^obbing of the parts within the 
chest. The last is the explanation adopted by Dr. Stokes. These 
different morbid conditions, under which an abnormal pulsation, cir- 
cumscribed or diffused, is discovered by palpation, are to be discrimi- 
nated, by calling to our aid, in addition to symptoms, the associated 
signs determined by the several methods of exploration. 

Fluctuation is occasionally distinctly felt in cases of chronic pleurisy, 
or empyema, in the distended intercostal spaces. I have met with an 
instance in which it was well marked over a large excavation in a 

* Vide Walshe on Diseases of the Lungs, etc., second London edition, 1S54, page 
396. 
2 Stokes on the Chest, second American edition, 1844, page 280. 



PALPATION. 325 

patient extremely emaciated. The concussion produced by liquid 
within a superficial cavity thrown with force against the thoracic 
walls by the act of coughing, is sometimes very plainly perceptible to 
the touch, as well as to the eye. 

The divergence and convergence of the ribs, whether persisting or 
incident to the respiratory movements, are appreciated by palpation 
better than by inspection. Placing a finger in the intercostal spaces, 
the two sides can be accurately compared with respect to their rela- 
tive width, and the relation of the ribs in respiration. In this 
way it may be ascertained, that when one side of the chest is 
enlarged, either by increased volume of lung or by pleural effusion, 
the lower intercostal spaces are widened, and those between the upper 
ribs narrowed. The ribs, under these circumstances, on the afi"ected 
side, will be found to remain comparatively motionless during the 
movements of respiration on the affected side, while, on the opposite 
side, those situated at the lower portion of the chest manifestly be- 
come more widely separated by the inspiratory act. Obliteration of 
the hollows between the ribs, from the pressure of a liquid, is more 
distinctly felt than seen. The smooth, even surface which charac- 
terizes the affected side in cases of chronic pleurisy, or empyema, with 
notable dilatation of the chest, is appreciated by the touch better 
than by the eye. In the same manner, tactile examination serves to 
distinguish the comparatively unequal enlargement due to emphy- 
sema. 

With the hand applied on the chest, the extent of motion at that 
part with inspiration is apparent. A comparison of the two sides at 
different points may in this way be made with respect to the relative 
amount of expansibility, the evidence obtained by ocular examination 
being thus confirmed or modified. In examining the female chest, if 
sensitiveness on the score of delicacy precludes a satisfactory exami- 
nation by inspection, palpation may be employed as an alternative. 

The respirations may be conveniently enumerated by means of pal- 
pation. In one respect this method has an advantage over inspection, 
viz., the movements being felt, the eyes are left unoccupied except 
to note the time during which the respirations are counted. In the 
female, the hand may be applied, for this object, in the infra-clavicular 
region ; in the male, the upper part of the abdomen is to be preferred. 

The situation of the apex impulse of the heart is sometimes an 
important point in the diagnosis of affections pertaining to the pulmo- 
nary organs. In large pleuritic effusions, and in some cases of em- 



326- PHYSICAL EXPLORATION OF THE CHEST. 

physema, the heart is removed from its normal situation. Under 
these circumstances the impulse may be felt, as well as seen, at a 
point more or less distant from that where it is to be sought for in 
health. A collection of liquid in the right pleural sac pushes the 
heart in a line somewhat diagonal, upward and outward, to the left 
of its normal situation. If the liquid be contained in the left pleural 
cavity, and sufficiently copious, the organ is carried upward and late- 
rally to the right, and may be found to pulsate between the fifth and 
seventh ribs to the right of the sternum. The absorption of large 
liquid effusions in either side also tends to displace the heart, through 
the influence of atmospherical pressure or suction. This effect, but 
to a less extent, has been observed in other affections attended with 
diminution of the bulk of the lung, viz., after absorption of inflamma- 
tory exudation, collapse or atrophy, and in cases of tuberculosis 
involving considerable destruction of the pulmonary substance. 
Absence of the heart's impulse, owing to its being pushed backward 
from the thoracic walls by the increased volume of the overlapping 
lung, is one of the signs of emphysema ; and in some instances of 
this affection, the organ is depressed, so that its impulse is transferred 
to the epigastrium. 

Finally, vibratory motions of the walls of the chest accompanying 
the act of speaking, and, under certain circumstances, respiration, 
constitute physical signs, possessing, in some cases, considerable im- 
portance. If the palmar surface of the hand be lightly applied over 
the healthy chest in certain situations, the vibrations of the vocal 
chords, propagated along the bronchial tubes, and communicated to 
the thoracic parietes, give rise to a thrilling sensation, called the 
vocal fremitus. This is strongly marked if the fingers are placed 
upon the larynx or trachea. It is more or less apparent in the infra- 
clavicular region ; in an inferior degree in the mammary and infra- 
mammary region ; ceasing below the line of hepatic dulness ; slight, 
if appreciable behind, over the scapulae ; generally felt, and sometimes 
well marked in the inter- and infra-scapular and axillary regions. 
The normal vocal fremitus, like the vocal resonance, the respiratory 
murmur, and the sound on percussion, is found to present great varia- 
tions in degree in different individuals entirely free from pulmonary 
disease. In some persons it is strongly marked ; in others moderate, 
in others slight ; and sometimes it is nowhere appreciable. Other 
things equal, it is stronger in proportion as the chest is thinly 
covered with fat and muscle. The character of the voice, also, 
materially affects its intensity. In general, the fremitus is notably 



PALPATION. 327 

Stronger in persons whose voices are powerful and low in pitch. It 
is therefore oftener, present, and is apt to be intense in adult males, 
than in females and children, whose voices are feebler and more 
acute. It is appreciated by the ear applied to the chest, even better 
than with the hand, and in connection with the subject of vocal reso- 
nance, it has already been incidentally noticed. As already remarked 
in that connection, the vocal fremitus does not sustain any fixed rela- 
tion to vocal resonance. The latter may be intense while the former 
is slight, and vice versa. This statement applies equally to health 
and disease. A loud shrill voice is most favorable for intensity of 
vocal resonance, whether normal or morbid ; on the contrary, as just 
stated, bass tones are most likely to give rise to a strong fremitus. 
The intensity of the fremitus, in health or disease, is affected by posi- 
tion. In the great majority of instances it is more strongly marked 
if the patient be recumbent, than in the sitting posture. 

With respect to the normal vocal fremitus, it is important to bear 
in mind that uniformity of the two sides of the chest is the exception 
rather than the rule. In the larger proportion of individuals it is 
more marked on the right than on the left side. This is true, not 
only of the summit of the chest, but at the lateral-posterior portion 
inferiorly. This natural disparity must be taken into account in 
estimating the effects produced by disease. 

The vocal fremitus may be increased, diminished, or suppressed, by 
morbid conditions. In a positive and negative point of view, there- 
fore, the voice, by means of palpation, furnishes physical evidence 
of disease. An increase of the vocal fremitus occurs in solidifi- 
cation of lung, especially from inflammatory exudation and tuber- 
culous deposit ; less frequently and in a less degree, in connection 
with oedema, extravasation of blood, or carcinoma. Dilatation of 
the bronchial tubes contributes to its intensity. Bearing in mind 
the disparity between the two sides just stated, a relatively greater 
amount of fremitus on the right than on the left side, affords equivo- 
cal evidence of the existence of disease. If, however, a greater 
amount be found on the left side, it is highly significant of a morbid 
condition. Seated at the summit of the chest, in conjunction with 
symptoms denoting a chronic pulmonary affection, it points to a 
tuberculous deposit. Existing in the left infra-scapular and infra- 
axillary regions, it is one of the signs indicative of consolidation from 
pneumonia. It becomes a valuable sign of the second stage of pneu- 
monia in some instances in which exaggerated vocal resonance, and 
even the bronchial respiration, are deficient. 



328 PHYSICAL EXPLOEATION OF THE CHEST. 

The normal Yocal fremitus is diminished or suppressed, as the rnle, 
whenerer the lung is removed from the thoracic walls hj the accn- 

mulation of liquid or gas within the pleural cavity. Some exceptions 
to this rule, as with respect to the absence of vocal resonance and re- 
spiratory sound, under similar circumstances, hare been observed. 
Generally, in cases of pleurisy with effusion, of hydrothorax, and of 
pnemno-hydrothorax, fremitus on the affected side is absent, or if 
present, relatively feeble. This negative sign is of more value if it 
be found on the ri^ht side, the rule in this instance beino^ the reverse 
of that applicable to increased fremitus. The reason for the rule is 
obvious. Were we to attempt to arrive at a diagnosis by exclusive 
reliance on the vocal fremitus, it would be necessary to enjoin caution 
not to regard the normal fremitus remaining on the left side, incases 
in which it is diminished or suppressed by disease on the right side, 
as proceeding from a morbid condition of the left lung. The liability 
to this error will always be obviated by attention to associated signs. 

In some cases of pleurisy, the vocal fremitus is increased at the sum- 
mit of the chest, over the lung condensed by compression, while it is 
feeble or null below the level of the liquid. 

In emphysema, the vocal fremitus is generally diminished, but, ac- 
cording to Walshe, this rule is not without exceptions, and the fre- 
mitus may even be increased. 

As already remarked, the normal vocal fremitus on the right side 
ceases below the line of hepatic dulness. In cases of enlargement of 
the liver, in which it encroaches on the thoracic space, absence of 
fremitus constitutes one of the signs assisting in determining the fact 
that the flatness on percussion, extending a greater or less distance 
above the normal limits, is not due to consolidated Ixmg. 

Certain motions of the chest, perceptible on manual examination, 
are occasionally incident to the respiratory movements. The bron- 
chial rales, both dry and moist, i. e. the mucous, sonorous, and sibi- 
lant, and the gurgling incident to cavities, sometimes cause a vibra- 
tory thrill, appreciable on application of the hand. This is called the 
rhonchal fremitus. In some of the instances in which a pleural fric- 
tion-sound is present, the rubbing of the roughened surfaces is 
distinctly apparent on palpation. This never occurs save when a 
friction-sound is, at the same time, strongly marked on auscultation. 
It is observed at a late stage in pleurisy, after absorption of liquid 
has brought the pleural surfaces into contact, the period of the disease 
when the friction-sound is oftenest observed, and is most apt to be 
loud and rough. 



palpation. 329 

Summary. 

Palpation furnislies information respecting the degree, situation, 
and extent of soreness of the chest ; the degree of elasticity of the 
thoracic walls ; the changes in form and size ; inequalities of the sur- 
face ; the condition of the intercostal spaces, and the amount of con- 
vergence or divergence of the ribs in respiration. 

In some instances, determining the existence of fluctuation, it esta- 
blishes the presence of liquid in the pleura, or in a superficial pul- 
monary excavation. It may be employed in estimating the extent of 
motion with the respiratory acts, and in a comparison of the two 
sides of the chest, in different situations, in this respect. It affords a 
convenient mode of enumerating the respirations. It is useful in 
determining whether the heart remains in its normal position, or has 
been dislocated in connection with disease affecting the pulmonary 
organs. 

The vocal fremitus, felt when the hand is applied to the healthy 
chest, is increased, diminished, or suppressed, in connection with 
different forms of disease. It is frequently increased in cases of 
solidification, especially from inflammatory exudation, and from tu- 
bercle. An increased amount of fremitus, situated on the left side, 
according to the part of the chest at which it is observed, is a signi- 
ficant sign of either phthisis, or pneumonia. Diminished or sup- 
pressed fremitus is incident to diseases in which the lungs are removed 
from contact with the thoracic walls, viz., pleurisy with effusion, and 
pneumo-hydrothorax. It coexists with flatness on percussion over 
the space occupied by an enlarged liver. Diminished and suppressed 
fremitus are much more valuable as physical signs, when they occur 
on the right side, in consequence of the normal fremitus being 
generally more marked on that side. 

A fremitus sometimes accompanies the bronchial rales, and gur- 
gling ; and a rubbing sensation is occasionally felt in conjunction with 
a loud and rough friction-sound, occurring in pleurisy, generally after 
the removal of the liquid effusion. 

History. 

The general remarks under this head, made with reference to In- 
spection, Chapter IV, are also applicable to palpation. The absence 
of the normal vocal fremitus, as a sign of pleuritic effusion, was first 
pointed out by M. Reynaud. 



CHAPTER VII. 

SUCCUSSION. 

Sudden agitation of the body, under certain circumstances of 
disease, occasions a splashing noise, which is quite pathognomonic. 
To produce it, the practitioner, applying his ear to the chest, grasps 
the shoulder of the patient, and moves abruptly, but not violently, 
the trunk backward and forward. This method of examination is^ 
called Succussion. A splashing noise is the only physical sign de- 
veloped by this method ; and, as just stated, it has a special significa- 
tion, representing, in the vast majority of the cases in which it 
occurs, a particular form of disease, viz., pleurisy with perforation, 
or the afi"ection commonly called pneumo-hydrothorax. 

The term splashing, is descriptive of the character of the noise. 
It may be imitated by shaking a bottle, partially filled with water, 
the remainder of the space being occupied with air. It is analogous 
to the gurgling occasionally produced in large pulmonary excavations 
by the impulse of the heart, and more especially, by acts of coughing. 
The conditions requisite for the production of the sign, are a cavity 
of large dimensions, partially filled with liquid, and partially with air 
or gas. These conditions obtain in pneumo-hydrothorax. In that 
afi'ection, air, or gas, and liquid, are contained within the pleural 
cavity. It involves, in the great majority of cases, perforation of 
the lung, but this is not essential to the production of the sign. Air 
and gas within the pleural sac, without communication with the bron- 
chial tubes, or externally through the thoracic walls, suffice for its 
manifestation. The sign would be entirely pathognomonic, except 
that it is sometimes observed in cases of a very large tuberculous ex- 
cavation. It is obvious that a cavity of great size may, at times, 
furnish the necessary physical conditions, viz., sufficiency of space 
containing liquid and air. With this exception (and the exceptional 
instances are extremely infrequent), the sign belongs exclusively to 
pneumo-hydrothorax. 



SUCCUSSION. 331 

The intensity of the splashing noise, and the facility with which it 
is produced, vary considerably in diiFerent cases. It may not be ap- 
parent save when the ear is either in contact with, or in close proxi- 
mity to the chest ; but in some instances, it is sufficiently loud to be 
heard at a distance. I have known it to be so intense as to be 
audible throughout a large lecture-room. It is produced, not alone 
by succussion practised for that purpose, but by any sudden, quick 
motions, sufficient to occasion agitation of the liquid. Hence, it not 
infrequently arrests the attention of the patient. Dr. Stokes relates 
a case, in which a patient, affected with pneumo-hydrothorax, was 
able to take horseback exercise, but whenever he rode in a gallop, or 
hard trot, he was annoyed by the splashing within the chest. An 
analogous case has fallen under my observation. The patient, a 
female, lived for several months after the occurrence of perforation 
in connection with tuberculosis, followed by pneumo-hydrothorax ; 
and retained sufficient strength to walk about, and to ride in the open 
air. Sudden change of position, rising up, sitting down, etc., pro- 
duced a splashing noise, very apparent to herself; and in riding in a 
carriage, every jolt was attended with the same effect. 

The sign is not uniformly present in cases of pneumo-hydrothorax. 
Its absence in a certain proportion of instances, probably depends on 
the too large proportion of liquid to the quantity of air or gas, or on 
the too great consistency of the liquid, or on both combined. The 
thinner the liquid the more readily is the splashing produced. The 
quality of the noise, as well as its intensity, varies. It sometimes has 
a high-pitched ringing character, and may be commingled with well- 
marked metallic tinkling. 

A noise resembling somewhat thoracic splashing originates within 
the stomach when this organ contains a certain quantity of liquid, 
and is at the same time distended with gas. The associated symp- 
toms and signs will always obviate the liability to doubt arising from 
this resemblance. Aside from the evidence afforded by succussion, 
the diagnostic criteria of pneumo-hydrothorax are unequivocal, so that 
the former might, without much inconvenience, be dispensed with. 
The diagnosis of phthisis, also, at the stage of the disease when it 
would be possible for succussion to be available, is sufficiently clear 
without resorting to this method of examination. 



332 PHYSICAL EXPLOBATION OT THE CHEST. 



Summary. 

Frequently in cases of pneumo-hydrothorax, and occasionally in 
cases of phthisis with a very large excavation, succnssion occasions a 
splashing noise, produced by the agitation of liquid in a space of con- 
siderable size, partially filled with air or gas. Owing, however, to 
the sufficiency of other signs, in connection with symptoms, this 
method of exploration is of trifling value with reference to diagnosis. 



ELestoet. 

Hippocrates was aware of the fact that by shaking the bodies of 
patients, a splashing noise was sometimes produced. This method 
was practised by him, and hence, the sign is sometimes called the 
" Hippocratic succussion-sound." The fact is also mentioned by 
several of the ancient writers. Hippocrates attributed the noise to 
the presence of pus, without recognizing the necessity of the presence 
of air or gas. He regarded it as a sign of empyema. Its patho- 
gnomonic significance has been established by modern investigations. 



CHAPTER VIII. 

RECAPITULATORY ENUMERATION OF THE PHYSICAL SIGNS 
FURNISHED BY THE SEVERAL METHODS OF EXPLORATION. 

I. Percussion. 

1. Exaggerated vesicular resonance. 

2. Diminished vesicular resonance. 

3. Absence of resonance. 

4. Tympanitic resonance. 

a. Amphoric. 
h. Cracked-metal. 
(Bruit depotfele.) 

11. Auscultation. 

PHENOMENA INCIDENT TO RESPIRATION. 

A. Modifications of the Intensity of the Vesicular Murmur, 

1. Increased intensity of vesicular murmur. 

2. Diminished intensity of vesicular murmur. 

3. Suppressed respiration. 

B. Modifications of the Quality, etc., of Respiratory Sounds, 

1. Bronchial respiration. 

2. Broncho-vesicular (rude) respiration. 

3. Cavernous and amphoric respiration. 

C. Modifications of the Rhythm of Respiratory Sounds, 

1. Shortened inspiration. 

2. Prolonged expiration. 

3. Interrupted inspiration or expiration. 

B. Adventitious Respiratory Sounds, 

1. Dry, vibratory, bronchial rales (sibilant and sonorous). 



I 

1 
I 

334 PHYSICAL EXPLORATION OF THE CHEST. 

2. Moist, bubbling, broncMal, or mucous rales (coarse and fine). 

3. Sub-crepitant rale. 

4. Crepitant rale. 

5. Gurgling. 

6. Indeterminate rales. 

a. Crumpling. 
h. Crackling. 

7. Friction or attrition-sounds. 



PHENOMENA INCIDENT TO THE VOICE. 

1. Exaggerated vocal resonance and bronchophony. 

2. Diminished and suppressed vocal resonance. 

3. Pectoriloquy and amphoric voice. 

4. ^gophony. 

PHENOMENA INCIDENT TO THE ACT OP COUGHING. 



1. Bronchial cough. 

2. Cavernous cough and amphoric cough. 

3. Metallic tinkling. 



PHENOMENA INCIDENT TO THE CIRCULATION. 

1. Abnormal transmission of heart-sounds. 

2. Arterial bellows-murmur. 



III. Inspection. 

A, Morbid Appearances pertaining to the Size and Form of the 

Chest. 

1. Enlargement. 

a. General. 
h. Partial. 

2. Contraction. 

a. General. 
h. Partial. 

B. Morbid Appearances pertaining to the Respiratory Movements* 
1. Abnormal frequency of the respirations. 



RECAPITULATION OF PHYSICAL SIGNS. 335 

2. Shortened inspiration. 

3. Prolonged expiration. 

4. Abdominal or diaphragmatic respiration. 

5. Costal or thoracic respiration. 

6. Exaggerated superior costal respiration. 

7. Respiratory movements on one side diminished or suppressed. 

8. Respiratory movements on one side exaggerated. 

9. Disparity in the superior costal movements between the two 

sides. 



lY. Mensuration. 

1. Alterations in size and form enumerated under the head of 

Inspection. 

2. Alterations in respiratory movements enumerated under the 

head of Inspection. 

y. Palpation. 

1. Tenderness on pressure. 

2. Increased or diminished elasticity of thoracic walls. 

3. Abnormal inequalities from depression or projection. 

4. Pulsation from cardiac impulse or arterial throbbing. 

5. Fluctuation. 

6. Abnormal conditions pertaining to intercostal spaces. 

7. Disparity between the two sides in expansibility, general or 

local. 

8. Abnormal situation of heart's impulse. 

9. Exaggerated vocal fremitus. 

10. Diminished or suppressed vocal fremitus. 

11. Rhonchal fremitus. 

12. Pleural rubbing. 

VI. SuccussiON. 
1. Splashing. 



CHAPTER IX. 

CORRELATION OF PHYSICAL SIGNS. 

Or the various morbid conditions to which, the respiratory organs 
are subject, each gives rise, almost invariably, to a group of physical 
phenomena. As with symptoms, so with signs, a greater or less 
number accompany individual diseases : and hence, they are rarely 
presented to the clinical observer isolated, but in certain combina- 
tions. In the diagnosis of intra-thoracic affections, it is seldom if 
ever the case that exclusive reliance is to be placed on a single sign, 
more than upon a separate symptom ; but the discrimination of one 
affection from another involves collective physical not less than vital 
evidence. Very few, if any, of the physical indications of pulmonary 
disease are pathognomonic. As a general rule, their diagnostic im- 
portance is in a great measure derived from union with each other ; 
and this aggregation of different signs, while it is often essential to 
diagnosis, always renders it much more exact and positive. A group 
of signs, no one of which by itself would be reliable, sometimes points 
to the nature and seat of a disease with greater 'precision than the 
most distinctive characteristic taken singly. To cite an illustration 
of this truth, the existence of tuberculous disease may be established 
by a series of phenomena, each of which, without the others, would 
possess trivial importance ; but, collectively, they render the diag- 
nosis as complete as possible. On the other hand, let one of the 
most significant of the physical signs be selected, for example metal- 
lic tinkling : guided by it exclusively, there would be a liability to 
error, for, although in the immense majority of the cases in which it 
is marked, it indicates pneumo-hydrothorax, it may occur in connec- 
tion with a large pulmonary excavation, and is simulated by sounds 
produced within the stomach. The accumulated evidence, in the first 
instance, overbalances the weight to be attached to the single sign, 
for reasons not unlike those which give to an abundance of circimi- 
stantial proof in courts of law greater force than belongs to the 
strongest direct testimony of a single individual. Again, not only 



CORRELATION OE PHYSICAL SIGNS. 337 

are physical signs individually insufficient as diagnostic criteria, but 
the same sign may be incident to different affections. The bronchial 
respiration, for instance, belongs equally to the semeiological history 
of pneumonitis and tuberculosis. Absence of respiratory sound 
occurs in cases of emphysema and in cases of pleurisy, — two very dis- 
similar forms of disease. The significance of particular signs, in such 
instances, depends in a great measure on the combinations in which 
they are found. Thus, absence of the respiratory murmur in emphy- 
sema is associated with an abnormal clearness of percussion-reso- 
nance ; on the other hand, in pleurisy, it is accompanied by flatness 
on percussion. The significance of the respiratory sign in these two 
instances is borrowed from the coexisting signs, the latter, it will 
be observed, being exactly opposite in their character. 

It is unnecessary to adduce farther illustrations to show the impor- 
tance of studying not only physical signs separately, but their mutual 
relations, by which they are united in groups or combinations, in 
connection with different morbid conditions. These relations have 
already, in the foregoing pages, to some extent been incidentally 
noticed, and hereafter, in treating of the diagnosis of individual 
diseases, the manner in which the physical phenomena furnished 
by the several methods of exploration are grouped will necessarily be 
considered. But, before entering on the second part of this work, 
there will be an advantage in devoting some attention to the correlation 
of physical signs; in other words, taking up, seriatim, certain im- 
portant phenomena pertaining to physical exploration, and enumerat- 
ing those with which each is found to be correlatively associated in 
clinical observation. To this object the present chapter will be de- 
voted. What are the different groups or combinations formed by the 
union of physical signs in consequence of their pathological affinities ? 
and what are the morbid conditions which these different groups or 
combinations of signs represent ? Although the answers to these 
questions involve to some extent a recapitulation of facts already pre- 
sented, and also an anticipation of points which are hereafter to be con- 
sidered, the student will not find it a useless expenditure of time to 
bestow some attention on the correlation of physical signs, in order to 
become more familiar with what may be termed the rules of syntax 
regulating the language of physical exploration, and as preliminary 
to the department of the subject which remains to be considered, viz., 
the diagnosis of particular diseases. 

To consider all the physical phenomena, respectively, which are 

22 



338 PHYSICAL EXPLOEATION OF THE CHEST. 

fumislied. hj the seyeral methods of exploration, would involve need- 
less and tedious repetitions. It will suffice to take up the individual 
signs belonging to percussion, and to auscultation so far as concerns 
respiratory and friction sounds. An enumeration of the signs sus- 
taining correlative relations to these, will be found to embrace the 
more important of the phenomena pertaining to auscultation of the 
voice, and to the remaining methods of exploration. Of the respira- 
tory signs, I shall omit those consisting in abnormal modifications of 
rhythm, because the two first, viz., shortened inspiration and pro- 
longed expiration, in the great proportion of instances, are merely 
elements either of the bronchial or the broncho-vesicular respiration, 
and the third modification, viz., interrupted respiration, belongs in 
the category with certain other phenomena, viz., the rales, which, it 
will be seen, cannot be said to have any correlative signs. Exclusive, 
then, of the modifications of rhythm, I shall proceed to take up, in 
the order in which they were enumerated in Chapter YIII, the phe- 
nomena furnished by percussion, and by auscultation so far as it re- 
lates to respiratory and friction sounds, presenting, briefly, the groups 
or combinations into which they respectively enter, by virtue of their 
relations to similar anatomical conditions of disease. 



Sia:S-S COREELATIVE TO THOSE FIJE^ISHED BY PeRCUSSIOK 

1. Exaggerated Vesicular Resonance. — Occurring in conse- 
quence of the activity of the lung on one side being supplementarily 
increased, the correlative sign pertaining to auscultation is an exagge- 
rated vesicular murmur. Under such circumstances, however, these 
signs are not intrinsically morbid. They are physiological phe- 
nomena exaggerated, but not to a point to be in themselves patho- 
logical, and they denote intra-thoracic disease, not at the portion of 
the chest corresponding to the situation where they are observed, but, 
inferentially, at another part, and generally on the opposite side. A 
correlative sign obtained by inspection and mensuration is increased 
extent of the respiratory movements. The pathological relation of 
exaggerated resonance to emphysema is more direct and important. 
The morbid condition in this affection consists in an abnormal accu- 
mulation of air, generally within the pulmonary cells, in some rare 
instances in the interlobular and sub-serous areolar tissue. The cor- 
relative sign derived from auscultation is directly the reverse of that 



CORKELATION OF PHYSICAL SIGNS. 339 

in the previous instance, viz., diminution of the respiratory murmur, 
amounting sometimes to suppression. This combination is highly 
significant. Other auscultatory signs are frequently associated, but 
they are incident, not purely to the emphysema, but to coexisting 
affections, especially bronchitis. This remark applies to the bron- 
chial rales so often present in cases of emphysema. Associated signs, 
determined by inspection, are thoracic enlargement, general or local, 
corresponding to the extent of the emphysematous dilatation ; dimi- 
nished respiratory movements ; obliteration of intercostal depressions ; 
diminished obliquity of the lower ribs ; divergence of the lower, and 
convergence of the upper ribs, if the emphysema be general. The 
relation of exaggerated resonance to emphysema is the rule ; but 
occasional exceptions are present in cases of great tension of the 
thoracic walls from the pressure of an over-distended lung. In these 
exceptional instances the resonance may be diminished in place of 
being exaggerated. The vesicular quality of resonance in cases of 
emphysema is rarely if ever lost, but it is more or less diminished. 
It is vesiculo-tympanitic. In proportion as the intensity of resonance 
is diminished by tension, the vesicular quality is impaired, and the 
tympanitic predominates. 

Exaggerated percussion-resonance incident to the temporary em- 
physematous condition which sometimes obtains in bronchitis, pul- 
monary catarrh, and bronchial spasm, involves, as correlative signs, 
the adventitious sounds which pertain to these affections, viz., the 
dry and moist bronchial rales. 

2. Diminished Vesicular Resonance. — In the exceptional in- 
stances of emphysema in which this modification of percussion-reso- 
nance occurs, the correlative signs will, of course, be the same which, 
in the majority of instances of that affection, are combined with exagge- 
rated resonance. 

Commonly the affections to which diminution of resonance is inci- 
dent are those involving either liquid pleural effusion, viz., pleurisy 
and hydrothorax ; or increased density of lung from deposit of liquid 
or solid matter, viz., pneumonitis, tuberculosis, oedema, pulmonary 
apoplexy, carcinoma, etc. The correlative signs in these two classes 
of affections are far from identical ; nor are they uniform in the 
different affections included in the same class. 

In pleuritic effusion sufficient to diminish but not abolish the 
vesicular resonance, correlative auscultatory signs are, diminished 



o4:0 PHYSICAL EXPLORATION OP IHZ CHZ5T. 

respiratory murmur, and in some instan : r ? :^ ;:;:'_:::- . ^ ; : : elatire 
Hgns determined by palpation are, diini:_:;_T- :: r: - irS^Ti Toeal 
vibration, and increased force of res:? : _ : t : : t ; - .: t 

In solidification from pneumonitis ancL riLDerciL.: -:s :_t correlatiTe 
anscnltatory phenomena, in the majority of insianii^j '^e more or 
less of the characters of the broncho-yesieTLlar, or oi the bronchial 
respiration, together "with exaggerated t:::' :^-: nance, or broncho- 
phony, and increased vocal fremitus. Ex:zp:::::.3.1 instances are not 
very infrequent ia which, instead of these signs being asBodxted, the 
respiratory sonnd is abolished and the vocal resonance and fremitus 
not increased. The latter constitute the rule, rather than the ex- 
ception, in the other affections involving abnormal density of Itmg, 
Tiz., oedema, pulmonary apoplexy, carcinoma, etc. 

A correlative sign in case? :f r^-'Tr-" ^n^. ^-?'? constantly :t_ 'tst" 
of pulmonary apoplexy, is t l t ; : ■ : . t \ . : : „ : :. . : The ere : . : : _ . . 7 
is generally associated with dimioished percussion-resonance in pneu- 
monitis, but the converse does not hold good to the same esbesit; in 
other words, the crepitant rale often appears before tJje -^ea^cfssmm- 
resonance is sensibly diminished. 

Diminished respiratory movements may be combined in all the 
affections named, but oftener in pneumonitis and tuberculosis. In- 
creased force of resit' : 1 : r on pressure, and diminished elasticity, is 
a correlative sign comniGii to all the varieties of solidification. 

3. Absejtge or Reboj? axce. — The anatomical conditaoBS ^wing rise 
to diminished resonance may be sufficient to abolish it, rendering the 
percussion-sound flat. Absolute flatness being in the great majority 
of instances due to the presence of a considerable quantity of liquid 
in the pleural cavity, the correlative auscultatory signs are absence 
of respiratory soiiiid, aaad of vocal resonance, with nota"*:];^ Rimini? te 5 
elasticity of the iJioraric walls. This combination of ::^ii :-. _L;_i- 
diagnostic ; yet the rule is not without exceptions, diffused bronchial 
respiration being associated with flatness in some c-:?rr :f large efiu- 
sion. Absence of vocal fremitus is another correla:.- ^ ;:;n. If the 
amount of effused liquid be great, inspection and mensuration fimiish 
important associated signs, viz., e-_li:^Tz:ent of the chest; ofeKtaaiitm 
of the hollows between the ribs. L-Tigence of tlie lower xodemk- 
vergence of the upper ribs; comparative immobility; elevation <rf 
the shoulder; widening of distance be:~fTi The nipple and the 
median line; depression of the IiFiar, and :ii::'al of the heart from 



CORRELATION OF PHYSICAL SIGNS. 841 

its normal position. Fluctuation is occasionally appreciable. This 
collection of signs incident to enlargement of the chest, may, how- 
ever, to a considerable extent, be reversed, in combination with flat- 
ness on percussion over the greater part of the chest. Absorption of 
the liquid effusion, inducing contraction, may take place, but not 
sufficiently to permit a return of percussion-resonance, with reappear- 
ance of respiratory sound, vocal resonance, and fremitus. Then, in 
connection with diminished size of the affected side, there will be 
convergence of the lower ribs, and divergence of the upper ; depres- 
sion of the shoulder, and narrowing of the distance between the 
nipple and the median line. Obliteration of the intercostal hollows 
and comparative immobility will be likely to continue. 

Flatness on percussion may accompany abundant tuberculous 
deposit, the second stage of pneumonitis, and other affections involving 
abnormal density of the pulmonary substance. The facts pertaining 
to correlative signs which have been stated under the head of dimi- 
nished resonance, or dulness, incident to pulmonary solidification, 
will be equally applicable, and need not be repeated. 

4. Tympanitic Resonance. — The signs associated with the differ- 
ent varieties of tympanitic resonance differ widely, according to the 
diversity of anatomical conditions represented. In the affection which 
presents, more than any other, a resonance purely tympanitic, strongly 
marked and diffused, viz., pneumo-hydrothorax, the correlative pheno- 
mena derived from auscultation are, the characteristic vocal, tussive, 
and respiratory sign, metallic tinkling ; feebleness or extinction of the 
vesicular murmur ; blowing and amphoric respiration, occasional and 
irregular ; absence of vocal resonance. Inspection and mensuration 
furnish the group of appearances incident to enlargement from liquid 
effusion. Palpation discloses absence or marked diminution of the 
normal vocal fremitus. Succussion developes the sign incident almost 
exclusively to this affection, viz., splashing. 

Tympanitic resonance, circumscribed in extent at the summit of 
the chest, sometimes metallic or amphoric, and occasionally present- 
ing a cracked-metal modification — these circumstances denoting its 
connection with a spacious pulmonary cavity, superficially situated, 
with rigid walls and free from liquid contents — exists in combination 
with cavernous respiration, presenting sometimes an amphoric intona- 
tion, alternating with gurgling ; occasionally splashing, with the act 
of coughing, and metallic tinkling ; pectoriloquy in some instances ; 



342 PHYSICAL EXPLORATION OF THE CHEST. 

local depression or flattening at the snminit of the chest, and deficient 
expansibility. 

Occurring, as an exception to the general rule, over lung solidified 
bj infiainniatOTj exudation, it is combined, of course, with the yarious 
pbenomena inddent to that anatomical condition. 

When presented in pleurisy, situated above the level of the liquid 
effbaion, and also oyer the healthy lung in cases of pneumonitis, it 
cannot be said to hare any definite correlative signs, irrespective of 
tbose which pertain to the diseases of which it is an incidental feature. 

Signs coreelatite to Sounds fuenished by AuscuLTATioiir. 

1. Increased Inten^sity op VESicrLAR Murmijr. — Proceeding 
always from hyper-activity of respiration iuduced supplementarily in a 
portion of the pulmonary apparatus, the correlative signs are exagge- 
rated percussion-resonance, and increased respiratory movements. The 
remarks made under the head of Exaggerated Yesicular Resonance are 
here equally applicable. 

2. Diminished Intensity of VESicrLAs MtiRMrR. — The pheno- 
mena associated with this sign are quite opposite in their character, 
corresponding to differences in morbid conditions which present a 
contrast equally striking. 

Abnormal feebleness of the vesicular murmur may be due to the 
removal of the lung at a certain distance from the thoracic wall. 
This removal is caused by the presence, in some cases, of air or gas ; 
in others, by a stratum of liquid or solid matter, and sometimes by 
air and liquid together, in the pleural cavity. In the first instance, 
a correlative percussion-sign is tympanitic resonance ; in the second 
instance, it is absence of resonance, or flatness : and in the third in- 
stance, both are conjoined, i. e. tympanitic resonance exists above the 
level of the liquid, and flatness below this level. The presence of air 
and liquid, constituting pneumo-hydrothorax, is, however, rery rarely 
characterized by simple feebleness of the respiratory sound : either 
the latter is aboHshed, or presents the cavernous or amphoric modifi- 
cation. Correlative signs iucident to this affection are metallic 
tinkling and a succussion-sound. Diminution of the respiratory 
motions, of vocal resonance, and fremitus, are common to the tliree 
morbid conditions just mentioned. 



COKRELATION OF PHYSICAL SIGNS. 343 

Again, feebleness of respiration, without change in quality or 
rhythm, occurs in a certain proportion of cases of solidification from 
tubercle, inflammatory exudation, oedema, etc. On the other hand, 
it is incident to emphysema, bronchitis, and partial obstruction at any 
point in the air-passages. In these two classes of morbid conditions 
the correlative percussion-signs are precisely reversed. In the first 
class it is combined with diminished resonance, or dulness ; in the 
second, the clearness of the percussion-sound is either undiminished or 
exaggerated. The anatomical condition in both instances is marked 
by the combination. Exclusive of the cases in which the lung is removed 
by liquid or solid matter, air, or gas, from the thoracic wall, feebleness 
of the respiratory murmur, combined with dulness on percussion, as 
the rule, denotes increased density of the pulmonary organ ; combined 
with normal resonance, it indicates that the density is neither increased 
nor diminished ; combined with exaggerated resonance, it is evidence 
of the abnormal rarefaction of the lung, pertaining to emphysema 
and some cases of bronchitis. Other signs existing in combination 
serve to establish the distinction as respects the anatomical condition. 
In cases of solidification, in which the efiect on the respiratory sound 
is simply to diminish its intensity, the vocal resonance may be exag- 
gerated, and even bronchophony may be present. In cases of rare- 
faction, this occurs only as rare exceptions to the general rule. The 
same remark will apply to vocal fremitus. Diminished respiratory 
motions may accompany both anatomical conditions. Enlargement of 
the chest, and its attendant phenomena, determined by inspection, 
mensuration, and palpation, pertain to emphysema. Diminished elas- 
ticity of the thoracic walls belongs to the former anatomical condition 
(increased density); increased elasticity to the latter (rarefaction). 

3. Suppressed Respikation. — Abolition of the sound of respira- 
tion, occurring in connection with the same diversity of morbid con- 
ditions as .diminished intensity of the respiratory murmur, presents 
similar combinations with other signs. 

Accumulation of liquid or gas, or both air and liquid, within the 
pleural sac, in sufficient quantity to render respiration inaudible, gives 
rise, in the first instance, to flatness on percussion ; in the second 
instance, to tympanitic resonance ; and in the third instance, to tym- 
panitic resonance above and flatness below the level of the liquid. 
Diminished respiratory movements, together with absence of vocal 
resonance and fremitus, are common to the three morbid conditions, 



344 PHYSICAL EXPLORATION OF THE CHEST. 

and, in addition, first in the order of time, are presented the pheno- 
mena attending enlargement of the chest, which need not be again 
enumerated ; and, second, the reversed phenomena following absorp- 
tion of the fluid, sufficient to induce contraction, but not to permit 
reappearance of the respiratory sound. 

In the cases of solidification from tubercle, inflammation, oedema, 
etc., in which suppression occurs, it is combined with notable dulness 
on percussion, as the rule, and with a clear tympanitic resonance, as an 
exception to the rule. Exaggerated vocal resonance, or bronchophony, 
and increased vocal fremitus, may exist in combination, together with 
diminished respiratory movements. On the contrary, in the cases of 
emphysema, in which the respiratory sound is lost, exaggerated per- 
cussion-resonance, with more or less of the tympanitic quality (vesi- 
culo-tympanitic resonance), is the associated sign as the rule, dulness 
being observed, as an exception to the rule, in some instances in 
which the tension of the thoracic wall, from distension, is very great. 
In the former anatomical condition (solidification), the elasticity of 
the parietes of the chest is notably diminished ; in the latter (rarefac- 
tion), the elasticity is increased. In connection with the suppressed 
respiratory sound incident to emphysema, the vocal resonance and 
fremitus are not exaggerated, save in some rare exceptional instances, 
the reverse being true, as already mentioned, of solidification. 

4. Bronchial Respiration. — The bronchial respiration represents 
solidification of lung, except when it occurs in connection with dilated 
bronchial tubes, increased density of the pulmonary parenchyma, in 
the latter case, being superadded. The correlative signs, therefore, 
are those which have direct relation to pulmonary solidification, as it 
exists more especially in tuberculosis and pneumonitis, the bronchial 
respiration being much oftener present and more strongly marked in 
these, than in other afi"ections in which the density of the lung is in- 
creased, viz., oedema, extravasation of blood, etc. The group of signs 
has been already given in connection with diminished vesicular per- 
cussion-resonance, and diminished or suppressed vesicular murmur, 
when these signs are due to the same anatomical condition, i. e. 
solidification. The associated signs, when the bronchial respiration 
exists, are much more uniform than those presented in combination 
with dulness or flatness on percussion, or with suppressed or dimi- 
nished respiration, owing to the fact, that the anatomical condition 
represented, in the vast majority of instances, by the bronchial respi- 



COEKELATION OF PHYSICAL SIGNS. 345 

ration, is the same, while the signs last mentioned are incident to ana- 
tomical conditions different, and, indeed, opposite, in their character. 
Dulness on percussion, exaggerated vocal resonance, or broncho- 
phony, increased vocal fremitus, diminished respiratory movements, 
increased force of resistance to pressure, are the signs sustaining a 
correlative relation to the bronchial respiration.^ 

5. Broncho-vesicular Respiration. — Representing slight or 
moderate increase of the density of lung, the correlative relations of 
this modification of the respiratory sound, are essentially similar to 
those belonging to the bronchial respiration. The difference is, the 
signs which may be associated are less frequently present, and, when 
present, are less marked. Dulness on percussion is comparatively 
slight, and may not be appreciable ; the vocal resonance and fremitus 
may not be obvious, and, if apparent, are weak ; the respiratory move- 
ments are, perhaps, not sensibly diminished, or, if so, in a small de- 
gree ; and impairment of the elasticity of the thoracic walls is either 
not determinable, or feeble. 

6. Cavernous and Amphoric Respiration. — Correlative cavern- 
ous signs form a group, each preserving always its significance, and not 
occurring in connection with other anatomical conditions. Actually, 
however, they are rarely combined, and, indeed, it is impossible for all 
of them to be present simultaneously, since some can only be pro- 
duced when the cavity is empty, and Others only when it is more or 
less filled with liquid. The correlative signs requiring an empty 
space, are the cavernous respiration, pectoriloquy, and circumscribed 
tympanitic percussion-resonance, inclusive of the metallic modifica- 
tion, and the cracked-metal sound. The correlative signs requiring 
the presence of liquid, are circumscribed dulness on percussion, 
gurgling, splashing with the act of coughing, and occasionally metal- 
lic tinkling. The two series of signs may occur in alternation. Both 
are incident to pulmonary cavities, tuberculous or otherwise, inclusive 
of pouch-like dilatation of the bronchial tubes ; and, also, in the 

' Under the head of Correlation of Physical Signs, I design to embrace only those 
which sustain toward each other direct relations. The signs incident to pleuritic effu- 
sion in the instances in which bronchial respiration exists over the compressed lung, 
are indirectly related, and therefore, not included among those to which the term cor- 
relative is applied. For the same reason, I do not enumerate among correlative signs 
those supplementarily induced by various affections in parts of the lungs more or less 
remote from the situation of the disease. 



346 PHYSICAL EXPLOEATION OF THE CHEST. 

pleural space, in connection "witli perforation, or, in other words, in 
pneumo-hydrotliorax. In the latter affection, the cavernous respira- 
tion oftener presents the amphoric character ; and the associated 
signs differ from those pertaining to pulmonary cavities. The per- 
cussion-resonance is more constantly tympanitic, is not circumscribed, 
but more or less diffused. Liquid, in greater or less quantity, is 
always present, and hence, flatness coexists with tympanitic reso- 
nance, the former situated above, and the latter below the level of 
the liquid. Metallic tinkling is generally observed, while in pulmo- 
nary cavities it is of rare occurrence. The succussion- sound is com- 
mon, which is exceedingly infrequent in cavities formed within the 
lungs. The phenomena attendant on enlargement of the chest, are 
generally present in cases of pneumo-hydrothorax, and absent in 
intra-pulmonary excavations. 

7. Adventitious Respiratory Souxds, or Rales. — The adven- 
titious sounds, or rales, may be considered under one heading, for, ex- 
cepting a single species, viz., gurgling, they resemble each other in not 
sustaining toward other signs any fixed correlative relations. In this 
respect, they offer a striking contrast to the signs already enumerated. 
The moist and dry bronchial rales, including the sub-crepitant, gene- 
rally represent pulmonary catarrh or bronchitis. They constitute all 
the positive or direct physical signs belonging to these affections. 
Other signs, it is true, are frequently found associated with them, 
but in such instances, pulmonary catarrh or bronchitis are superadded 
to other affections. The connection is one of coincidence, not of 
a pathological relation. This deficiency of correlative signs has a 
positive and important bearing on diagnosis. The presence of the 
bronchial rales, taken in connection with the absence of abnormal 
percussion-sound, or other signs, establishes the existence of the diseases 
which they represent, disconnected from other affections. The crepi- 
tant rale represents, in the great majority of the instances in which 
it is observed, pneumonitis. Pneumonitis during its career presents, 
as has been seen, a group of correlative signs ; but the crepitant rale, 
strictly speaking, cannot be considered to stand in a correlative re- 
lation to any of them, for it is developed often prior to their appear- 
ance, and although it very frequently persists after other signs have 
appeared, this is by no means uniformly the case. Moreover, in a 
certain proportion of cases, it does not appear during the course of 
the affection. In the instance of this disease, as of bronchitis, the 



CORRELATION OF PHYSICAL SIGNv«l. 347 

absence of coexisting signs is an important point, for, in connection 
with certain symptoms, it may denote the existence of pneumonitis, 
not advanced sufficiently to give rise to the pathological changes 
represented by associated signs. This point ma}'- have a material 
influence on the therapeutical management of the disease. The in- 
determinate rales, although often combined with other physical phe- 
nomena, and deriving much of their diagnostic significance from the 
combination, have, nevertheless, no fixed or definite correlative signs. 
In other words, there are no signs involving the coexistence, even in 
a considerable proportion of instances only, of the indeterminate 
rales. 

8. Friction-Sounds. — These resemble the foregoing rales in not 
sustaining definite correlative relations to other signs. They differ, 
however, in this respect, viz., clinically, they are very rarely found 
isolated ; they are associated with signs to which they do not stand in 
a fixed or uniform relation. The associated signs are different, ac- 
cording to the different circumstances under which the friction-sounds 
are developed. Representing, in the great majority of instances, 
pleuritis, they may or may not be associated with the physical evi- 
dences of a certain amount of liquid effusion. Occurring either at 
the commencement or at a late period in the career of the disease, 
they may or may not be accompanied by the phenomena pertaining 
to contraction of the chest. Being incident not only to simple pleu- 
risy, but occasionally to pleurisy developed as a complication of 
tuberculosis and pneumonitis, they may be found in combination with 
the groups of the physical signs representing the latter affections. 



PAET II. 

DIAGNOSIS OF DISEASES AFFECTING THE 
EESPIRATOEY ORGANS. 



PART 11. 

DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY 

ORGANS. 



PRELIMINARY REMARKS. 

The diagnosis of diseases affecting the organs of respiration in- 
volves the practical application of the principles which it has been 
the object, in the preceding pages, to elucidate. In the investiga- 
tion of diseases, however, at the bedside, the attention is by no 
means to be directed solely to signs. Invaluable as they are, their 
importance is greatly enhanced by association with symptoms and 
the knowledge of pathological laws. The results of physical explora- 
tion alone, frequently leave room for doubt, and liability to error, 
when a due appreciation of vital phenomena and of facts embraced in 
the natural history of diseases, insures accuracy and positiveness. 
An overweening confidence in the former is to be deprecated as well 
as exclusive reliance on the latter. And since the practical discrimi- 
nation of intra-thoracic affections is always to be based on the com- 
bined evidence afforded by these three sources of information, in 
treating of the subject, it is desirable that the attention shall not be 
limited to one source to the exclusion of the others. In taking up, 
therefore, in the succeeding pages, the diagnosis of individual diseases, 
I shall not disconnect entirely physical signs from symptoms and 
pathological laws. After premising a few considerations, the signs 
belonging to each disease will be considered ; and under the head of 
Diagnosis I shall adduce symptoms and pathological laws which are 
to be associated with the phenomena furnished by physical exploration 
in the discrimination of the disease. The diseases affecting the 
respiratory organs, may be distributed according to their proximate 
anatomical relations into the following groups : 1. Those affecting 
the bronchial tubes ; 2. Those more immediately connected with the 
air-cells and pulmonary parenchyma ; 3. Those seated in the pleura. 
I shall take up the particular diseases embraced in these three groups, 
in the order just enumerated. Diseases affecting the trachea and 
larynx will form a fourth group. 



CHAPTER I. 

BROXCHITIS— PULMOXARY OR BROXCHIAL CATARRH. 

Broxchitis, or inflammation of the mucous membrane lining the 
bronchial tubes, admits of being divided, nosologically, into two forms, 
the distinction being based on difference in seat. In one form, the 
inflammation is confined to the larger subdivisions of the bronchi ; in 
the other form, it is either restricted to the minute branches, or more 
commonly affects them and the larger subdivisions also. In the 
great majority of cases the disease is presented in the first form, and, 
consequently, this may be distinguished as ordinary hroncMtis. The 
second form is generally called capillary hroncliitis. This title im- 
plies that the inflammation is seated in the capillary bronchial tubes, 
*^hich is not the fact ; the smaller ramifications are affected, but not 
the terminal twigs of the bronchial tree, or bronchioles, which are, 
properly speaking, the capillary tubes. This form offers striking 
peculiarities as regards symptoms, physical signs, and pathological 
laws. 

Another division, based on the duration and degree of the inflam- 
mation, is into acute and chronic bronchitis. 

The inflammation may be developed in the bronchial tubes as a 
primitive, idiopathic affection ; and it may coexist with other diseases, 
seated either in the pulmonary organs, or elsewhere. Important 
points of difference pertain to this distinction. 

The affection may be general; in other words, invading the bron- 
chial tubes to a greater or less extent on both sides ; and it may be 
partial or circumscribed, in the latter case occurring almost invariably 
as a complication of some other antecedent pulmonary disease. 

Farther divisions were formerly made, based on the predominance 
of certain symptoms, for example, the quantity and quality of the 
liquid products expelled from the bronchial tubes. By writers of the 
present day, these differences, although constituting important modi- 
fications of the disease, are deemed insufficient grounds for multiply- 



ACUTE BRONCHITIS. 353 

ing nosological distinctions. The occurrence of a plastic or fibrinous 
exudation on the mucous surface, however, is a peculiarity sufficiently 
striking and important to serve as the basis of a distinct variety. 

In treating of bronchitis with reference to its diagnosis, I shall 
consider under separate heads the following divisions : 

1. Acute bronchitis. Under this head I include cases in which the 
disease, in addition to its acuteness, is idiopathic, and limited to the 
larger subdivisions ; in other vfords ordinary, and primary acute 
bronchitis. 

2. Capilbxy bronchitis. 

3. Pseudo-membranous or plastic bronchitis. 

4. Chronic bronchitis. 

5. Secondary bronchitis. 

Acute Bronchitis. 

The circumstances pertaining to the anatomical characters of 
acute bronchitis, which stand in immediate causative relation to 
the development of the characteristic physical signs are, unequal 
diminution of the calibre of the affected tubes, from swelling or 
thickening of the membrane, and more especially, from the presence 
of tenacious mucus ; the presence or absence of li{|uid in the tubes ; 
the quantity when present ; the facility with which it is moved from 
place to place, and permeated by air ; the size of the tubes, among 
those of large or medium dimensions, in which the disease and its 
products are chiefly situated ; obstruction, temporary or persisting, 
of some of the tubes, diminishing or cutting off the supply of air to 
the vesicles to a greater or less extent, and sometimes condensation 
of pulmonary lobules proportionate to the number and size of the 
obstructed tubes. 

Physical Signs. — Percussion, in general, furnishes no positive 
signs in bronchitis, but negatively the information which it affords 
is of greater practical importance than any of the positive signs 
pertaining to the disease.. Clearness of the percussion-resonance 
is a fundamental point in the diagnosis. As the rule, it holds good 
that the resonance continues vesicular and undiminished, and it is 
sometimes increased. The exceptions to this rule are very infre- 
quent. Moderate dulness, situated at the posterior and inferior part 
of the chest, has been observed as the result of the accumulation 



354 DISEASES or THE EESPIRATORY ORGANS. 

within the broncliial tubes of the liquid products of inflammation. 
toward the close of the disease in fatal cases characterized by an 
abundant secretion of these products. Collapse of portions of the 
luns from obstruction of certain of the tubes mav also sire rise to 
dulness. These exceptions do but little toward invalidating the rule. 
In the vast majority of the instances in which the resonance on 
percussion is found to be diminished, the bronchial affection is a com- 
plication of some other pulmonary disease. The existence of bron- 
chitis having been determined by symptoms, laws, and positive signs, 
the fact of the percussion-sound remaining clear serves to establish 
its idiopathic character. 

With an unimportant exception, auscultation furnishes all the posi- 
tive physical signs of bronchitis. These consist of the dry and moist 
bronchial rales. During the early part of the disease, so long as the 
matter of the expectoration is slight and adhesive, the rales are dry, 
generally sonorous, but- sometimes approximating to the sibilant. 
The moist or mucous rales follow, when the liquid contained in the 
bronchial tubes becomes more abundant and less viscid. Both de- 
scription of rales may be afterward commingled in varied proportions. 
The varieties of the dry and moist rales, with their distinctive fluctua- 
tions as respects intensity, persistency, etc., have been abeady fully 
described, and it is unnecessary to reproduce in this connection 
details relative to these points. It will suffice to mention the fol- 
lowing practical considerations. The dry rales alone do not consti- 
tute adequate proof of the existence of bronchitis, for contraction of 
the bronchial tubes from spasm, with, and even without, simple irrita- 
tion of the mucous membrane, suffices for their production. Nor do 
bubbling rales, of themselves, invariably denote the disease, for they 
may proceed from blood, pus, as well as serum and mucus, within the 
tubes, without necessarily involving bronchial inflammation. If, how- 
ever, the two classes of sounds occur in succession, or if they are found 
to be commingled, the diagnostic evidence either of bronchitis or 
bronchial catarrh is complete, but whether primary or secondary is 
to be determined by other signs. 

The occurrence of moist rales succeeding the dry, is in general to 
be considered evidence of the progress of inflammation toward reso- 
lution. 

The combination of dry rales of different grades as respects pitch, 
in other words, the grave tones of the sonorous rale accompanying 
expu'ation, united with sounds approaching in acuteness the sibilant 



ACUTE BKONCHITIS. 855 

rale, the latter heard especially with inspiration, render it probable 
that the bronchial inflammation extends over a considerable area, em- 
bracing the smaller bronchial subdivisions. This conclusion is also 
warranted by the combination of the coarse and fine varieties jof the 
moist or bubbling rales. Another indication of the extent of the 
bronchial tree affected, is afforded by the diffusion of the rales over 
the chest. If the inflammation be confined to the larger tubes, the 
rales will be found to originate within a section corresponding to the 
middle third in front and behind ; if they emanate from the upper 
and lower thirds, the fact shows that the inflammation extends be- 
yond the larger tubes. 

Absence of the rales is by no means proof that bronchitis does not 
exist. Both the dry and moist bronchial rales are evanescent and 
variable. They may be absent at one examination and present at 
the next ; or they may disappear and reappear during the same exa- 
mination. The different varieties may be presented in succession, 
alternation, and in varied combinations. These diversities have been 
already described. But repeated explorations, in some cases of 
bronchitis, fail to discover any of the positive auscultatory signs. 
The physical conditions necessary for the production of the rales may 
not exist, or be present irregularly, and for brief periods, and thus 
they escape observation. 

The loudness of the rales and their constancy are not commensu- 
rate with the intensity or extent of the bronchial inflammation. The 
physical conditions requisite for the production of the dry and moist 
rales, may be present in a more marked degree in certain cases of 
mild bronchitis, than in other cases in which the disease is severe. 
A little reflection in connection with the mechanism of the produc- 
tion of these rales, will render the fact just stated intelligible. 

Finally, a highly important practical consideration is, the rales 
incident to idiopathic bronchitis are heard on both sides of the chest. 
The law of symmetry pertaining to this disease is often useful in the 
diagnosis, and hence, the value of the physical signs of the existence 
of the bronchial inflammation on the two sides. 

The vesicular murmur is frequently obscured, or even drowned by 
the bronchial rales. At the commencement of the disease, before 
the dry rales are developed, the murmur is frequently abnormally 
loud, the expiration being somewhat prolonged, as in exaggerated 
respiration ; the sound is also rough or harsh. This increased inten- 
sity and roughness of quality may persist, if the characters of the 



356 DISEASES OF THE RESPIRATORY OEGAXS. 

vesicular respiration are not masked bj the presence of the rales. 
These modifications of the respiratory murmur are observed espe- 
cially at the superior portion of the chest. In some cases of bron- 
chitis the murmur is heard throughout the continuance of the disease, 
apparently not materially modified as respects either its intensity or 
character. This is true of certain cases in which the inflammation 
is not severe, confined to the larger tubes, unaccompanied by much 
swelling of the membrane, and the secretion of mucus slight. The 
vesicular murmur is diminished oftener than exaggerated during the 
progress of bronchitis, and not unfrequently it is suppressed partially 
or generally over the chest. Partial suppression may be caused by 
plugging of certain of the larger bronchial tubes with tenacious 
mucus, interrupting the passage of air sufficiently to abolish sound. 
In this way bronchial rales, as well as the vesicular murmur, beyond 
the seat of the obstruction, may be arrested. Situated in the pri- 
mary or secondary divisions of the bronchi, the interruption to the 
passage of air may cause suppression over a considerable portion of 
the chest. It is conceivable, indeed, that the quantity and force of 
the current of air received by inspiration may be diminished by the 
adherence of the tenacious products of inflammation to the surface of 
the larger tubes of both lungs, so as to abolish universally respiratory 
sound, and yet the obstruction not be great enough to occasion 
marked dyspnosa. That partial suppression is frequently due to this 
cause, is shown by the vesicular murmur being suddenly developed 
after an act of coughing, in a portion of the chest where just preced- 
ing this act it had not been appreciable, — a fact often observed in 
auscultating patients afi'ected with this disease. This suggests a 
procedure which should be resorted to, in order to determine whether 
the diminution or suppression proceed from the presence of liquid 
products, viz., requesting the patient to make a voluntary efi*ort of 
coughing, and auscultating immediately afterward. If the respiratory 
sound, with or without rales, reappear, or become more intense in 
a situation where, prior to the act of coughing, it was either absent or 
feeble, the result shows that the diminution or suppression proceeded 
from a movable cause of obstruction. The result may follow an act 
of coughing without expectoration, the collection of mucus being de- 
tached and thrown forward into tubes of larger size, to be subse- 
quently expectorated. The tumefaction and thickening of the 
mucous membrane may be sufficient to diminish, and even abolish, 
the vesicular murmur, in cases in which the inflammation extends to 



ACUTE BRONCHITIS. 35T 

the smaller bronchial tubes. Marked diminution or suppression of 
respiratory sound generally over the chest, under these circum- 
stances, is evidence of the extent of the bronchial inflammation. The 
emphysematous dilatation of the air-cells is another circumstance 
tending to enfeeble the vesicular murmur. 

As regards the other methods of exploration, inspection and palpa- 
tion enable us to ascertain whether the respiratory movements are 
morbidly frequent, or abnormally modified. In the form of bron- 
chitis under present consideration, the frequency of the respirations 
is rarely more than moderately increased, and usually they are not 
notably labored or attended by dyspnoea. The superior and inferior 
costal types of breathing are frequently somewhat more developed 
than in health. On applying the hand to the chest a vibration or fre- 
mitus may in some instances be felt, which is incident to the bron- 
chial rales, and called the rhonchal fremitus. This is of little practical 
importance, inasmuch as it affords no information in addition to that 
obtained more satisfactorily by auscultation. 

Diagnosis. — The diagnosis of acute bronchitis, with the aid of phy- 
sical exploration, is generally unattended with difficulty. Prior to the 
discovery of auscultation, it was confessedly impracticable, in many 
instances, to discriminate between inflammations affecting the mucous, 
serous, and parenchymatous structures. The application of physical 
signs having rendered this discrimination easy and positive in the great 
majority of cases, has thereby contributed to the more successful study 
of the semeiological history of these different affections ; so that at the 
present time, the diagnostic importance of symptoms and pathological 
laws is much better understood than previously. Yet, even now, 
cases not infrequently present themselves of which the diagnosis would 
be difficult and uncertain without the aid of exploration. Cases 
of pneumonitis and pleuritic are occasionally wanting in their most 
distinctive symptomatic phenomena; and, on the other hand, cases 
of bronchitis are sometimes equally deficient in its peculiar features. 
The differential diagnosis, under these circumstances, must rest mainly 
on physical signs. But in cases of a less doubtful description than 
those just supposed, the physical signs enable the physician to dis- 
criminate with greater promptness, ease, and confidence, as well as 
with much less actual liability to error, than if he relied exclusively 
on the symptoms. So far as the results of exploration are con- 
cerned, the discrimination of idiopathic bronchitis from pneumonitis 



358 DISEASES OF THE RESPIRATORY ORGANS. 

and pleurisy inYolves, first, undiminished resonance on percussion on 
botli sides. In pneumonitis and plem-itis, as will be seen hereafter, 
dulness or flatness occurs on one side soon after the invasion. In 
bronchitis, the air-vesicles remaining filled with air, and sometimes 
even abnormally distended, the percussion-sound retains its normal 
clearness, while in pneumonitis the presence of solid matter within 
the vesicles, and in pleuritis the presence of liquid in the pleural 
cavity, diminish or abolish the resonance. Second: the bronchial 
rales, generally but not invariably present to a greater or less extent in 
bronchitis, exist on both sides of the chest. Bronchitis may complicate 
both pneumonitis and pleurisy, but the two latter afi'ections being con- 
fined to one side in the vast majority of instances, the bronchial rales 
are manifested chiefly on the affected side. On the other hand, idio- 
pathic or primary bronchitis is a symmetrical disease, and the bronchial 
rales when present are generally heard on both sides. It is in this 
way that the law of symmetry has an important bearing on the diagnosis. 
Third : in uncomplicated bronchitis certain distinctive physical signs 
present in cases of pneumonitis and pleuritis are absent. This point, 
like the first, is essentially negative, but its bearing on the diagnosis 
is quite positive. In pleuritis, auscultatoi-y and other signs of liquid 
in the pleural sac, are readily appreciable. In pneumonitis, the evi- 
dence, other than that furnished by percussion, of solidification of lung, 
together with the characteristic rale (the crepitant), are generally 
available. Hence, absence of the physical phenomena which charac- 
terize these two affections warrants their exclusion. 

Lobar pneumonitis, the ordinary form of the disease in the adult, 
is referred to in the foregoing remarks. The form occurring in 
young children, viz., lobular pneumonitis, in which the inflammation 
attacks isolated pulmonary lobules on both sides, is habitually asso- 
ciated with bronchitis, and hence called broncho-pneumonia. The 
diagnostic marks by which broncho-pneumonia is distinguished from 
simple bronchitis are much less distinctly defined than those which 
contrast it with lobar pneumonitis. The discrimination is in fact not 
always easy. Evidence derived from physical exploration is incom- 
plete, owing to the positive signs of pneumonitis being generally want- 
ing or imperfectly developed in this form of the disease. Symptoms 
are more to be relied upon than signs. And the symptoms indicating 
lobular pneumonitis in connection with bronchial inflammation, are 
those which show the respiratory function to be compromised to a 
greater extent than is usual in cases of uncomplicated bronchitis, ^iz., 



ACUTE BRONCHITIS. 359 

frequency of tlie respirations ; dilatation of the alse nasi ; lividity of 
prolabia, etc. If in connection with the local symptoms of ordinary 
bronchitis, the respiration be but little accelerated, the alse not dilated, 
the blood properly oxygenated, and the physical signs of pneumo- 
nitis not discoverable, the affection may be considered to be simply 
bronchial inflammation ; but if, in connection with the same local 
symptoms, the respirations are hurried, the alse dilating, the blood 
imperfectly oxygenated, even with the absence of the characteristic 
signs of pneumonitis, the disease nevertheless may be broncho-pneu- 
monia. The absence of the signs which are characteristic of lobar 
pneumonitis, viz., the crepitant rale, relative dulness of percussion- 
sound on one side, bronchial respiration, bronchophony, and exag- 
gerated fremitus, do not authorize the exclusion of lobular pneumonitis, 
because all these signs may be wanting in cases of the latter form of 
the disease. But this subject will be considered more fully in con- 
nection with the diagnosis of broncho-pneumonia. In the suppositions 
just made, an important qualification is introduced. It is assumed 
that the bronchitis is of the ordinary form ; in other words, that the 
inflammation does not extend to the minute bronchial branches. 
General capillary bronchitis compromises the respiratory function to a 
greater extent than broncho-pneumonia ; and hence, great frequency 
of the respirations, dilatation of the alae, and lividity, may indicate the 
former, instead of the latter afl'ection. The difl'erential diagnosis of 
these affections, however, will present itself for consideration more 
appropriately hereafter. 

The liability of confounding tuberculosis of the lungs with bron- 
chitis, relates rather to the chronic than the acute form of the latter 
afl'ection. In some cases of acute phthisis, the abrupt invasion and 
rapid progress of the disease, may lead the physician, at first, to 
suppose that he has to deal simply with acute bronchitis. With due 
investigation this error should be avoided. The fact of acute bron- 
chitis being preceded, in a large proportion of instances, by inflam- 
mation or irritation of the air-passages above the trachea, has some 
bearing on this discrimination. In tuberculosis, the symptoms from the 
first are oftener pulmonary. The coincidence of acute bronchitis and 
the development of tuberculous disease occurs in only a small proportion 
of cases. Hence, if an acute pulmonary afl'ection have been ushered 
in by catarrh, or coryza, gradually advancing downward to the pul- 
monary organs, the presumption is in favor of its being simple bron- 
chitis. Other points of difl'erence are entitled to vastly more weight 



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ACUTE BRONCHITIS. 861 

fevers. It forms an important constituent, in a pretty large propor- 
tion of cases of rubeola ; and being present in a greater or less degree 
frequently in typlms and typhoid fevers, it may constitute a prominent 
feature of these affections. There is a liability, under these circum- 
stances, to consider the disease simply and exclusively bronchitis. 
In rubeola, the bronchial symptoms preceding for several days the 
appearance of the eruption, this error does not necessarily imply 
want of care or skill on the part of the diagnostician. The chief dis- 
tinguishing points are the degree and persi^ency of the coryza, the 
irritation or inflammation extending along the lacrymal passages to 
the conjunctiva, and the disproportion between the local evidences 
of bronchitis and the general symptoms, such as febrile movement, 
pain in head and loins, loss of appetite, etc. These points, however, 
are not infrequently unavailable ; and, in fact, in a certain propor- 
tion of cases, it is difficult, if not quite impossible, to predict with posi- 
tiveness that the affection will prove to be more than bronchitis. In 
continued fever the difficulty is less, and, indeed, with due attention 
and knowledge, it should rarely exist. Except in some occasional in- 
stances, continued fever is not ushered in by marked symptoms of a 
bronchial affection ; these symptoms become developed after the fever 
is confirmed. The disease has a prodromic period, in which usually 
other phenomena are more prominent than those pertaining to the pul- 
monary organs. Limiting the attention to typhoid fever, the form 
of continued fever generally observed in this country, and the form 
in which the bronchial element is oftener marked, the duration of the 
stage of invasion and the characteristic symptoms frequently present 
in this stage, suffice for the diagnosis. Afterward, in addition to the 
characters then present denoting the disease, viz., the abdominal 
symptoms, epistaxis, eruption, etc., the pulmonary affection compared 
with the febrile movement, the prostration, anorexia, etc., is dispro- 
portionately mild. The rales observed are the sonorous and sibilant, 
more especially the latter ; and these continue, rarely merging into, 
or becoming combined with, the mucous rales. The facility with 
which the discrimination is made, in the vast majority of cases, renders 
it superfluous to dwell longer on the details of the differential 
diagnosis. 



S62 DISEASES OE IHS SE3PIB.AT0E.T OEG-AXS. 



ST^niAlLY OF THE PHTSICAJL SIGNS EELON'GIXG- TO ACITTE ORMXAST 

BRONCHITIS, 

Percussion-resonance clear on both sides of the chest. In the 
earlj stage^ before liquid secretion takes place, the dry rales, espe- 
ciallj the sonorons, irregnlarlj present in a certain proportion of 
cases. After secretion, the moist rales frequently conuniQgled with 
the dry. The rales heard on both sides. The respiratory murmur 
at the upper portion of the chest in front exaggerated and harsh in 
the early stage. Subsequently liable to be dimiaished or suppressed 
OTer a part or the whole of the chest. Sometimes reproduced 
saddenly after an act of coughing. In some mild cases preserving 
its normal intensity and characters. A rhonchal fremiius occasion- 
ally present. 

Capit.laky BEoa"CHrTis. 

Bronchitis is distinguished as capiLIary, when the inflammation in- 
rades the minute bronchial branches. Inflammation of the larger 
tubes generally, but not unifol-mly, coexists. The capillary tubes or 
bronchioles, in other words, the terminal subdiyisions, are not neces- 
sarily implicated. Extending to the latter, and limited to more or less 
of the pulmonary lobules, the affection called broncho-pneumonia is 
superadded. Capillary bronchitis was formerly described hj medical 
writers under the titles, peripneumonia notha, and suffocative catarrh. 
Its true character and seat have been but recently understood. It 
is with great propriety considered to be a distinct form of bronchitis, 
differing from the ordinary form in important particulars, pertaining 
to symptoms, laws, and signs, as well as to anatomical characters. 

The anatomical conditions, on which the physical signs are immedi- 
ately dependent, are, irregular contraction of the calibre of the minute 
tubes, the presence of liquid within these tubes, and obstruction to the 
passage of air to and from the vesicles. The latter condition, i. e, the 
obstruction, is that to which the most distinctive and important 
symptoms stand in immediate relation. 

Physical Signs and Diagnosis. — In capillary/as in ordinary bron- 
chitis, the air within the pulmonary vesicles remainiQg undiminished, 
andj indeed, increased in quantity (excepting the reduction due to 



CAPILLARY BRONCHITIS. 363 

the collapse of lobules, which takes place, to a greater or less extent, 
in a certain proportion of cases, the percussion-resonance is unim- 
paired, and acquires an exaggerated clearness, especially at the supe- 
rior and anterior portion of the chest. A clear sound on percussion, 
and equal on the two sides, although negative, is a fundamental point 
in the diagnosis. Dulness denotes either that the affection is compli- 
cated with pneumonitis, or that a certain amount of collapse has 
taken place. 

Auscultation furnishes, at the early part of the disease, and to a 
greater or less extent during its career, the dry bronchial rales. 
Both the sonorous and sibilant are incident to this variety of bron- 
chitis, but the latter is characteristic of extension to the minute tubes. 
The sibilant rale is sometimes in a marked degree acute or whistling 
in its character. The sonorous rales may be loud and musical, as in 
cases of asthma, being appreciable by the patient himself and by 
others. Both varieties are generally diffused over the whole chest. 
The presence of the rales tends to drown the vesicular murmur, but 
the latter is rendered feeble, and may be abolished by the obstruction 
within the tubes, and the over-distension of the cells. The moist or 
mucous rales incident to ordinary bronchitis may be present, more or 
less, depending on the inflammation of the larger tubes, which usually 
coexists, and the amount of the consequent mucous secretion. But a 
moist rale characteristic of an affection of the minute tubes is the suh- 
crepitant. This rale in its sensible characters, as well as in its 
source, holds an intermediate place between the mucous, on the one 
hand, and the crepitant (intra-vesicular), on the other hand. It is a 
bubbling rale, conveying to the ear the impression of the presence of 
liquid. The bubbles seem to be small, and somewhat unequal in 
size. The sound is finer than that of the finest mucous rales. It 
may accompany either inspiration or expiration, or both respiratory 
acts. Contrasted with the sub-crepitant, the crepitant rale is still 
finer ; it is dry, i. e. not conveying the idea of bubbles, and in fact 
does not belong in the category of the bubbling rales ; the crepita- 
tions are equal, and it is limited to the inspiratory act. These 
several points of distinction enable the auscultator to discriminate 
between the two in the majority of instances, by the sensible charac- 
ters alone.^ The law of symmetry here, as in the ordinary form of 

' In a case of capillary bronchitis complicated with lobar pneumonitis in the adult, 
the sub-crepitant rale accompanied both respiratory acts, and the crepitant was distinctly 
appreciable at the end of inspiration. 



364 DISEASES OF THE EESPIEATOEY ORGANS. 

bronchitis, has an important bearing on the diagnosis. In confor- 
mity with this law the snb-crepitant rale is found on both sides of 
the chest. This is a point distiagnishing it from the crepitant rale 
which, in the vast majority of cases, is limited to one side. It is true 
that, capillary bronchitis occurring generally in children, the dis- 
crimination is to be made between it and the lobular form of pneii- 
monitis in which the inflammation affects both sides. But, as will 
be seen hereafter, in lobular pneumonitis the crepitant rale is rarely 
appreciable. 

The sub-crepitant rale in capillary bronchitis is heard especially 
OTer the lower third of the chest posteriorly. Present in this situation, 
diffused over a considerable space, on both sides, and the percussion- 
resonance unimpaired, this combiuation of signs in connection with 
the symptoms of the disease, renders the diagnosis positive. The 
sub-crepitant rale, under these circumstances, becomes pathogno- 
monic. Aside from its connection with capillary bronchitis, this rale 
occurs iQ oedema of the lungs, in haemoptysis, in some cases of 
phtliisis, and in pneumonitis. But the associated signs and symp- 
toms in all cases render it sufficiently easy to distinguish between 
these several affections and idiopathic capillary bronchitis. (Edema 
is a secondary affection, frequently limited to one side, and gives 
rise to dulness on percussion. In haemoptysis, the bloody expectora- 
tion indicates the source of the sign, and hemorrhage (excepting the 
bloody streaks which the sputa occasionally present), does not belong 
among the events liable to occur in this, more than the ordinary form 
of bronchitis. In phthisis, the sub-crepitant rale is an occasional 
sign limited to a circumscribed space at the summit of the chest, and 
associated with more or less of the other signs, as well as with the 
symptoms denoting tuberculosis. In pneumonitis it occurs at a late 
stage of the disease, after the diagnosis has been determined, but the 
connection is easily established by the concomitant physical signs, 
viz., bronchial respiration, bronchophony, dulness on percussion, etc., 
these signs being, in the vast majority of cases, limited to one side 
of the chest. 

If the practitioner were to be guided exclusively by the symptoms, 
he might be at a loss in some instances to decide between the exis- 
tence of capillary bronchitis, and acute pneumonitis, or pleuritis, 
occurring in the adult, albeit the distinguishin;g features of the for- 
mer, as contrast-ed with the two latter affections, are of a strikuiflr 
character. Acute pneumonitis and pleuritis are generally charac- 



CAPILLARY BRONCHITIS. 365 

terized by sharp, lancinating pains, which do not enter into the symp- 
tomatic history of capillary bronchitis. The latter, in the great 
majority of instances, supervenes either on ordinary bronchitis or pul- 
momonary catarrh. The former are preceded by an inflammatory or 
catarrhal afi"ection of the bronchial mucous membrane in only a small 
proportion of cases. They are frequently ushered in by a chill, which 
is not observed to accompany the onset of capillary bronchitis. The 
suffering with orthopnoea, the cyanotic hue of the lips and surface, 
the great frequency of the pulse, the rapid progress frequently to a 
fatal issue, distinguish severe cases of capillary bronchitis ; these 
symptoms not being present to the same extent, save in rare excep- 
tional cases, of pneumonitis and pleuritis. But with the aid of physi- 
cal exploration the discrimination is made with so little difficulty that 
it is not necessary to dwell on the subject. Both pneumonitis and 
pleuritis speedily present certain positive signs, so constantly present 
and so easily appreciated, that their absence warrants the exclusion 
of these affections. These signs are incident to solidification of the 
lung in pneumonitis, and the presence of liquid effusion in pleuritis. 
In the vast majority of instances they are confined to one side 
in both affections. On the other hand, the sub-crepitant rale, and 
the dry rales belonging to capillary bronchitis, are diffused uni- 
versally over the chest. The fact, however, is not to be lost sight of, 
that capillary bronchitis may become complicated with lobar pneu- 
monitis in the adult ; and it is to be borne in mind that in these re- 
marks the form of pneumonia peculiar to children (broncho-pneu- 
monia) is not referred to. 

An instance has fallen under my observation of acute phthisis in 
which the tuberculous deposit was so abundant and rapid as to induce 
great difficulty of respiration, accompanied with very rapid pulse, 
lividity of prolabia and face, and ending fatally by asphyxia within a 
fortnight. But in this case haemoptysis occuiTed, and the physical 
I signs denoted plainly tuberculous consolidation, most marked at the 
summit of the chest. In such an instance, an error of diagnosis could 
only befall one who depended entirely on symptoms. 

Other diseases for which there is a liability of capillary bronchitis 
being mistaken, and vice versa, are, first, certain affections of the 
larynx, inducing the phenomena of asphyxia ; and, second, certain 
pulmonary affections in addition to those already mentioned, viz., 
asthma, ordinary bronchitis in connection with emphysema, lobular 
pneumonitis, or broncho-pneumonia, and the variety of bronchitis to 
be next noticed, called plastic or pseudo-membranous. 



366 



DISEASES OF THE EESPIRATORT ORGANS. 



The laryngeal affeenons referred to. are oedema glottidis, spasm 0-: 
the glottis (laryngismus stridulus), acute laryngitis in the adult, and 
in children croup. In oedema glottidis, the seat of the obstruction i? 
indicated by the sudden arrest of the inspiration, the expiration re- 
maining free : the reverse obtains in capillary bronchitis. Either 
ordinary bronchitis or pulmonary catarrh precede and accompany 
it as a coincidence, not as a law. Auscultation, if there be no pul- 
monary complication, discovers only diminution or abolition of the 
vesicular murmur: not the rales incident to capillary bronchitis. 
Moreover, with the finger carried to the top of the larynx, the exis- 
tence of the oedema may be demonstratively settled by the touch. 

Spasm of the glottis, rare in the adult, but not uncommon in early 
life, is a paroxysmal affection, the respiration, in the intervals being 
either free, or but slightly embarrassed. It is characterized fre- 
quently by a sonorous crowing inspiration, distinctive of its laryngeal 
origin. It is unaccompanied by the frequency of the pulse which 
belongs to capillary bronchitis. The difficulty of respiration incident 
to the latter, although increased at times, is persisting. The positive 
signs of inflammation of the minute bronchial tubes are wanting. 

Laryngitis in the adult, and croup in children, present distinctive 
characters referable to the voice, in addition to other points of dif- 
ference. The voice is hoarse, husky, or extinguished, while its quality 
remains unaffected 'm capillary bronchitis. Moreover, in croup the 
sonorous tubular breathing and cough are diagnostic. The absence 
of the auscultatory signs of capillary bronchitis in both these affec- 
tions, as in the foregoing instances, renders the diagnosis positive. 

A paroxysm of asthma is characterized by symptoms not unlike 
those presented in capillary bronchitis. The orthopnoea and evidences 
of defective haematosis are similar in the two affections. The situa- 
tion of the obstruction is the same, viz., in the minute bronchial 
branches ; and the physical signs, exclusive of the mucous and sub- 
crepitant rales, are identical in character. The sonorous and sibi- 
lant rales are equally, or even more, marked in asthma. But in 
this affection the pathological element is spasm. The affection is pa- 
roxysmal, although the paroxysms may have considerable duration. 
The liability of the patient to attacks of asthma is known, since in 
the great majority of instanc-es they occur in persons who are habi- 
tuated to them. Generally, the previous history and physical signs 
denote the pre-existence of emphysema. The pulse furnishes a grand 
point of difference. In asthma, the pulse may remain unaffected in 



CAPILLARY BRONCHITIS. 867 

frequency, and never is accelerated to the degree observed in capil- 
lary bronchitis. 

Acute bronchial inflammation extending beyond the larger, but not 
to the minute branches, occurring in a person affected -with emphy- 
sema, induces a train of symptoms resembling closely those of the 
capillary form of bronchitis. The suffering and labor with respi- 
ration, and the impaired oxygenation of the blood, may be equally 
marked, but the prognosis is far less grave. The existence of emphy- 
sema is readily determined by present signs taken in connection with 
the previous history. The sonorous and sibilant rales will be likely 
to be present in connection with the mucous rales, but not the sub- 
crepitant. The coexistence of the emphysema renders the symptoms 
pertaining to the respiration and hsematosis much less ominous than 
if this complication did not exist. The pulse, which, under these 
circumstances, is a better index of immediate danger than the symp- 
toms just referred to, is less frequent than in capillary bronchitis. 

Mild capillary bronchitis occurring in an emphysematous subject, 
gives rise to dyspnoea out of proportion to the actual amount of obstruc- 
tion. Moreover, as such subjects are generally liable to asthma, spasm of 
the muscular fibres of the bronchial tubes is a more prominent element 
than in cases in which the capillary bronchitis is uncomplicated, 
and hence the diflSculty of breathing is in a more marked degree 
paroxysmal. Under these circumstances the pulse denotes less 
intensity of inflammation and danger than might be inferred from the 
pulmonary symptoms alone. These facts, however, have relation 
to the prognosis, and the importance of active therapeutical inter- 
ference, rather than to the diagnosis. 

The affection with which capillary bronchitis is most likely to be 
confounded, and from which it is with most difficulty distinguished, 
is lobular pneumonitis or broncho-pneumonia. Both affections are 
peculiar to young subjects, and hence, occasions are oftener presented 
to the practitioner for discriminating between these, than between 
capillary bronchitis and the other form of disease, to which in some 
of its features it bears resemblance. Moreover, capillary bronchitis 
and broncho-pneumonia may actually be combined ; and, in fact, the 
latter probably always involves inflammation of the minute bronchial 
branches in direct communication with the inflamed lobules. In 
capillary bronchitis, the inflammation extends from the larger to the 
minute bronchial tubes generally throughout the pulmonary organs, 
either with or without the air-cells of more or less of the lobules be- 



368 DISEASES OF THE RESPIRATORY ORGANS. 

coming implicated. In broncho-pneumonia, the inflammation extends 
from the larger tubes to a certain number of the air-cells of the 
lobules on each side, affecting, of course, the intermediate minute 
branches leading to the lobules which have become inflamed, but 
limited to these, and in this respect differing very materially from 
general capillary bronchitis. In both affections, ordinary bronchitis 
exists, with the symptoms and signs incident thereto. In both, the 
respirations are hurried, with more or less dyspnoea, and perhaps with 
evidences of defective hsematosis. 

In the lobular form of pneumonitis, as has been already stated, 
and as will appear more fully hereafter, the characteristic physical 
signs, as well as certain symptoms pertaining to lobar inflammation 
of the pulmonary parenchyma, are frequently wanting. The crepi- 
tant rale, the bronchial respiration and bronchophony, are often not 
discoverable. The matter of expectoration in young children is 
swallowed. In view of these facts, how is the differential diagnosis 
to be made ? The following are the chief points of distinction. Gene- 
ral capillary bronchitis, as a rule, is a graver affection than lobular 
pneumonitis ; the respirations are more frequent ; the asphyxiating 
effects are greater, and the symptoms representing these effects, viz., 
dyspnoea, restlessness, lividity, in a corresponding degree more marked. 
In fatal cases, the career of the disease is more rapid. With refe- 
rence to physical signs, one source of difficulty is the incompleteness 
of the explorations with which the physician must be content in ex- 
amining young children. With care and perseverance the character- 
istic phenomena of pneumonitis may, in some cases, be discovered. 
In addition to the auscultatory phenomena just mentioned, if the 
number of lobules consolidated by inflammation be considerably more 
numerous on one side than on the other^ relative dulness on percus- 
sion may be apparent. But the same result will follow collapse of a 
greater number of lobules on one side from bronchial obstruction. 
The sub-crepitant rale belongs to both affections, but in lobular pneu- 
monitis it is limited in its seat to the minute tubes in immediate re- 
lation to the inflamed lobules, while in general capillary bronchitis 
the physical conditions for the production of the sound exist every- 
where throughout the lungs. In the latter affection, therefore, the 
sub-crepitant rale is diffused over the whole surface of the chest ; and 
in the former it is limited to certain portions. This is the most dis- 
tinctive evidence to be obtained by physical exploration, provided the 
positive signs of pneumonitis are not to be discovered. In the in- 



PSEUDO-MEMBRANOUS BRONCHITIS. 

stances in which the signs are appreciable, the diagnosis is, of course, 
established. 

With due attention to the foregoing points of distinction, cases will 
occur in which the discrimination is difficult, if not impossible. And 
it may be remarked that the uncertainty which must attach to the 
differential diagnosis in certain instances, accords with the present 
unsettled pathological views respecting the connection between bron- 
chitis and morbid conditions heretofore considered to be dependent 
on inflammation of the pulmonary lobules. E-ecent researches tend 
to show that in a large proportion of the cases of the so-called broncho- 
pneumonia, the disease is exclusively bronchial inflammation, leading 
to collapse of the lobules to a greater or less extent. 

Finally, capillary bronchitis presents symptoms and signs belonging 
alike to the form of bronchial inflammation called plastic or pseudo- 
membranous, which will presently be noticed under a distinct head. 
Remarks on the diagnostic points distinguishing these affections from 
each other, will be more appropriate in connection with the latter. 

SUMMARY OP THE PHYSICAL SIGNS BELONGING TO ACUTE CAPILLARY 

BRONCHITIS. 

Percussion-resonance on both sides not diminished, but often 
exaggerated ; sonorous and sibilant rales diffused over the chest, the 
latter more prominent and abundant than in ordinary bronchitis ; 
the sub-crepitant rale on both sides, and observed especially at the 
inferior posterior portion of the chest ; coarse and fine mucous rales 
intermingled to a greater or less extent. 



Pseudo-membranous or Plastic Bronchitis. 

This variety of bronchitis is characterized by the exudation of 
fibrin on the mucous surface of the smaller bronchial tubes, forming 
what is termed false membrane, identical with the deposit which takes 
place within the larynx and trachea in croup. The false membrane, 
in cases of croup, sometimes extends downward into the bronchial 
subdivisions. These cases are not embraced under the present head. 
The deposit in plastic or pseudo-membranous bronchitis commences 
in the minute branches, and extends upward towards the trachea. A 
fibrinous exudation in some of the tubes is occasionally observed as a 
contingent anatomical element of capillary bronchitis ; but it is the 

21 



370 DISEASES OF THE KESPIRATOPwT ORGAXS. 

basis of a distinct form of bronchial inflammation, Tvlien it constitutes 
the most distinctive and important featm^e of the disease. Patho- 
logically, it denotes a peculiar modification, without necessarily great 
intensity of the inflammatory process. 

The expectoration of croupal matter is preceded by cough more 
or less violent, generally accompanied by dyspnoea. These character- 
istic sputa are expectorated at intervals varying greatly in difi'erent 
cases ; days, weeks, months, and sometimes even years intervening. 
Aside from this peculiar featm-e, the symptoms may be those of an 
acute or sub-acute bronchial inflammation. Dyspnoea and the evi- 
dences of defective h^ematosis may be absent, or present in a degree 
proportionate to the amount of obstruction, and the number of the 
bronchial ramifications afi'ected. The danger and the rapid career 
of the disease depend on the circumstances just mentioned. The ex- 
pectoration of false membrane may be followed by relief more or less 
complete. Collapse of pulmonary lobules, or solidification from an 
extension of the inflammation to the air-cells, will add to the gi-avity 
of the symptoms, and the danger. Cases in which the exudation 
takes place extensively throughout the lungs, present all the distress- 
ing and alarming symptoms incident to severe capillary bronchitis, 
and under these circumstances the disease may prove rapidly fatal. 
In other instances, a small number only of the bronchial ramifications 
being affected, the symptoms are comparatively mild, and not indica- 
tive of immediate danger. Under the latter circumstances, the 
affection may continue indefinitely, or recur from time to time, or, 
after the expectoration of the membranous products, terminate in 
complete recovery. 

This form of bronchitis is exceedingly rare. It occurs in males 
oftener than in females. It is not limited to any period of life, but 
it is most frequent between the ages of twenty and fifty. Persons 
debilitated, or who have previously had some pulmonary affection, are 
more liable to the disease than those in robust health. Hemoptysis 
is an event not belonging to this more than to other forms of bron- 
chitis, irrespective of the bloody points or streaks which the sputa 
occasionally present. 

The affection may be acute or chronic. It may be partial, i. e. 
affecting a certain number of the bronchial tubes only ; or general, 
extending over the greater portion of the tubes. It obeys the law of 
symmetry, like the other varieties of bronchitis, when it is idiopathic. 
If the exudation take place extensively, or if it occur in connection 



PSEUDO-MEMBRANOUS BRONCHITIS. 371 

with other pulmonary affections, a fatal result may be expected. Of 
the cases, however, in which false membrane, in more or less abun- 
dance is expectorated, a large proportion end in recovery.-^ 

Physical Signs and Diagnosis, — The physical signs in plastic or 
pseudo-membranous bronchitis do not differ materially from those 
incident to the varieties of the disease previously considered. Ex- 
clusive of certain incidental morbid conditions, viz., collapse, solidi- 
fication from inflammation, and great accumulation of liquid products 
within the air-tubes, percussion elicits a resonance clear and equal 
on the two sides. The sonorous and sibilant rales will be likety to 
be heard, on auscultation, more or less diffused over both sides of the 
chest. The moist or bubbling rales are developed in the progress of 
the disease, as in the other forms of bronchitis. Suppression of the 
rales and of all respiratory sound over portions of the chest, is liable 
II to occur from obstruction of the tubes by the exudation, in which 
case it may be temporary, and variable in situation and extent; or 
from oollapse and solidification, in the latter case being more persisting 
both in seat and duration. The sub-crepitant rale may be discovered, 
but limited to certain portions of the chest. A diagnostic point per- 
tains to the fact last stated. The presence of the sub-crepitant rale 
distinguishes this from ordinary bronchitis. The limited extent of 
surface over which the rale is heard, distinguishes the affection from 
capillary bronchitis. In the latter variety, the sub-crepitant rale is 
diffused over the chest. It is proper to add, however, that the point 
of distinction just stated is determined inferentially, rather than by 
induction from a sufficient number of clinical observations. M. Barth 
and M. Cazeaux, separately, have reported each a single case in which 
a peculiar valvular or flapping sound {petit bruit cle soupape), was 
heard on auscultation, attributed to the vibration of partially de- 
tached portions of membranous exudation. It is doubtful whether 
the sound be sufficiently distinctive to represent the presence of this 
peculiar product within the tubes. Were it a diagnostic sign, the fact 
of its being only occasionally observed, v/ould render it practically of 
little value. 

The diagnosis of plastic or pseudo-membranous bronchitis, as dis- 
tinguished from other varieties of inflammation of the bronchial 
mucous membrane, must be based almost exclusively on the charac- 



^ For the results of an analysis of forty-eight cases, collected from various sources, by 
Dr. Peacock, vide London Med. Times, Dec. 1S54, and American Jour, of Med. 
Sciences, April, 1S55. 



3*2 DISEASES OF THE RESPIRATORY ORGANS. 

teristic expectoration. Prior to false membrane being expelled, the 
symptoms and signs are not sufficiently distinctive for the practitioner 
to decide that this particular form of bronchitis exists. If membran- 
ous formations are discoyered in the matter of expectoration, their 
appearance may at once denote their source, and, consequently, the 
locality of the inflammation, as well as its peculiar character. 
Solid or cylindrical casts not only show their bronchial origin, but 
indicate the size, and, in some measure, the extent of the tubes in- 
Yolyed. Bat if the false membrane expectorated consist simply of 
fragmentary pieces or shreds, the fact of the exudation being bron- 
chial is settled by the quality of the voice remaining unaffected, and 
the absence of other evidences of laryngeal disease. The circum- 
stances just mentioned suffice for the differential diagnosis between 
croup, and plastic or pseudo-membranous bronchitis. 

The period of life at which this affection is most apt to occur, has 
some importance in a diagnostic point of view. In this respect it 
differs from capillary bronchitis, as well as croup. The latter are 
eminently infantile diseases, while the affection under consideration is 
oftenest observed in persons between the ages of twenty and fifty. 
The age of the patient is entitled to a certain amount of influence, in 
forming a probable opinion of the character of the disease before it 
is settled by the characteristic expectoration. 

It should be added, that the occurrence of the characteristic ex- 
pectoration is not invariable. The disease may run on rapidly to a 
fatal termination, before sufficient time has elapsed for the processes 
upon which the exfoliation of the croupal exudation depends, to be 
completed. 

The discrimination of this form of bronchitis from affections other 
than bronchitis, which compromise respiration and the function of 
haematosis, and therefore have certain symptoms in common, involves 
the same diagnostic points already noticed in treating of ordinary 
and capillary bronchitis, and it would be superfluous to reproduce 
them in this connection. 

stdi:mary of the phtsical siaxs belongin-g to plastic or pseudo- 
membranous BRONCHITIS. 

In addition to the physical phenomena, positive and negative, inci- 
dent to other varieties of bronchitis, a peculiar valvular or flapping 
sound [hruit de mupape) has been observed. The sub-crepitant rale, 
if present, less diffused than in most cases of capillary bronchitis. 



CHRONIC BRONCHITIS. 373 



Chronic Bronchitis. 

Bronchitis, existing primarily as an acute affection, may be pro- 
longed and assume the chronic form, but occasionally the inflamma- 
tion is subacute from the commencement. Contrasted with the 
acute variety of the disease, chronic bronchitis offers some important 
points of difference, not only in its symptoms, effects, and patholo- 
gical relations, but as regards the affections from which, clinically, it 
is to be distinguished. It therefore merits separate consideration. 

Pliysieal Signs. — So long as chronic bronchitis remains uncompli- 
cated with any other pulmonary affection, or with lesions affecting 
the size of the tubes or cells, which are apt to supervene, the chest 
yields a clear vesicular resonance on percussion. The only excep- 
tion to this rule is, occasionally the occurrence of slight or mode- 
rate dulness from excessive accumulation of the liquid products of 
the inflammation within the bronchial tubes. Exclusive of this ex- 
ception, marked disparity between the two sides as respects reso- 
nance, assuming the chest to be well formed and symmetrical, de- 
notes that the bronchitis is complicated with some affection which 
either increases the density of the lung, such as collapse, pneumonitis, 
tuberculosis ; or, on the other hand, abnormal rarefaction from em- 
physema. Complications exist in chronic, oftener than in acute 
bronchitis; and hence, clearness and equality of the percussion-re- 
sonance are found in connection with the symptoms of the former, less 
commonly than in the latter affection. 

The bronchial rales, moist and dry, are heard in different cases 
with every diversity as respects character, intensity, combination, 
and relative predominance of the different varieties. The bubbling 
rales will be abundant and diffused in proportion to the quantity of 
liquid within the tubes, its thinness admitting the passage of air, and 
the extent of its distribution. The sound will be loud and coarse 
when produced in the larger tubes ; finer and less intense in the 
smaller branches. These rales will predominate in cases characte- 
rized by copious expectoration. The vibrating rales will be especially 
prominent in cases in which the matter of expectoration is small in 
quantity and viscid, adhering tenaciously to the walls of the tubes, 
and not readily traversed by air. In cases characterized by the for- 
mation of small solid mucous pellets (dry catarrh), a clicking, valvular 
sound, was described by Laennec as occasionally present, and attributed 



374 SISSASEiS € 



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CHRONIC BRONCHITIS. 375 

not confirmed bj subsequent observations. And it is probably this 
modification which Dr. Bowditch terms a mucous respiration} A 
rational explanation is, that the swelling of the mucous membrane, 
or the presence of a little mucus, occasions an audible bronchial 
sound, but does not furnish the physical conditions for a fully deve- 
loped dry or moist rale. 

The vocal resonance and fremitus in chronic bronchitis, as the 
rule, remain unafi'ected. The exceptions to this rule are certainly 
extremely infrequent. Exclusive of the vibration perceptible to the 
touch which sometimes accompanies loud rales, it may be doubted if 
exceptions ever occur, provided the bronchitis be uncomplicated. 
The relatively greater degree of resonance and fremitus on the right 
side in health, which in some persons is marked, may have given rise 
to apparent exceptions to this rule. 

Diagnosis. — The diagnosis of chronic bronchitis, so far as concerns 
the determination of the fact of its existence, is attended practically 
with little or no difficulty. The points which call for attentive and 
skilful investigation, relate to the presence or absence of compli- 
cations and resulting lesions. Is the bronchitis uncomplicated ? or 
is it associated with dilated bronchise, emphysema, pneumonitis, 
chronic pleuritis, or tuberculosis ? These questions are not answered 
so easily as the simple inquiry whether chronic bronchitis be or be 
not present. In general terms, the coexistence of other morbid condi- 
tions than those pertaining to the mucous membrane is to be deter- 
mined by the presence or absence of the signs and symptoms which 
belong to them respectively. The signs and symptoms distinctive 
of other affections will, of course, be embraced in the consideration 
of these affections individually, hereafter, and it would involve a 
needless repetition to introduce them in this connection. Of the 
several affections mentioned, the question of the coexistence of tuber- 
culosis with the symptoms of chronic bronchitis is oftenest presented 
in practice ; and there are few problems in diagnosis more important 
than the discrimination of the latter uncombined, from its combina- 
tion with the former. Is this simply a case of chronic bronchitis, or 
is there superadded a deposit of tubercle ? is a question not unfre- 
quently arising in medical practice, which is of momentous import to 
the patient, and which, for many reasons, it is extremely desirable 
for the practitioner to be able to answer definitively. Prior to the 
introduction of physical exploration, this question often presented 

' The Young Stethoscopist, page 38, second edition. 



376 DISEASES OF THE RESPIRATORY ORGANS. 

insnperable difficulty. Cases of chronic broncliitis were considered 
cases of phthisis, and vice versa; and it was impossible to aToid these 
errors. Thej are now necessarily incident to the practice of those 
who ignore physical diagnosis. In yiew of the importance of this 
discrimination, some of the points which it involyes may be here 
mentioned, but the subject could not be fully considered without 
anticipating what will more appropriately come under the head of 
the diagnosis of tuberculosis. The discrimination is to be based 
mainly on the presence or absence of more or less of the positiye 
indications of tubercle : but there are certain considerations pertaining 
to the symptoms, signs, and laws of chronic bronchitis, which have 
a bearing on the question, and in cases in which the positiye evidence 
of tubercle is doubtful, are entitled to considerable weight ui the 
diagnosis. To these considerations attention will be at present limited. 
Chronic bronchitis occurring at the period of life when the tubercu- 
lous deposit generally takes place, succeeds, in the majority of cases, 
the acute form of the disease. Tuberculosis is ushered in by acute 
bronchitis in but a small proportion of cases. Hence, in a doubtful 
case, if acute bronchitis have existed at the commencement, the 
chances are in favor of its not being phthisis. Pain is generally 
absent in chronic bronchitis, and, if present, is slight, dull, and sub- 
sternal. Acute stitch pains are very common in the course of 
phthisis, due to the circumscribed pleuritis which almost invariably 
accompanies tubercle ; and they are referred to the summit of the 
cliest on one side, or frequently to beneath the scapula. The respira- 
tions are habitually more or less accelerated in phthisis. This ob- 
tains rarely in chronic bronchitis, and if it occur is generally in 
paroxysms. The pulse is often notably accelerated in phthisis, rarely 
in chronic bronchitis. Febrile paroxysms, occurring generally in the 
progress of tuberculosis, do not belong to the history of chronic bron- 
chitis. Haemoptysis is an event of very frequent occurrence in 
phthisis, and, excepting the occasional bloody streaks which the sputa 
present, it is never incident to mere bronchitis. The characteristic 
sputa of tuberculosis, viz., solid, nummular masses, striated, parti- 
colored, with ragged edges, are not observed in bronchitis. The 
microscope reveals ia the sputa of phthisical patients, frequently, 
fibres exfoliated from the pulmonary structure. These do not enter 
into the composition of the sputa furnished by the bronchial mucous 
membrane. The loss of weight iu phthisis is generally considerable 
and progressive. It is less marked in chronic bronchitis. 



I SECONDAEY BRONCHITIS. 377 

i 

i The bronchial rales are incident to phthisis, as well as to chronic 
I bronchitis ; but in the latter affection they are most apt to be heard, 
I or are more abundant, at the inferior and posterior part of the chest 
I on both sides. In the former affection they are heard at the superior 
j part of the chest in front, and frequently either limited to, or more 
pronounced, on one side. The preceding points are quite distinctive ; 
but, in addition, in tuberculosis there are present more or less of the 
positive signs of that disease, rendering the evidence complete. These 
will be enumerated hereafter in treating of the diagnosis of tubercu- 
lous disease. 

SUMMARY or THE PHYSICAL SIGNS BELONGING TO CHRONIC BRONCHITIS. 

Clearness of the resonance on percussion. The dry and moist 
bronchial rales, variously intermingled, frequently but not invariably 
present, heard especially over the base of the lungs on both sides. 
A harsh respiratory sound occasionally present. The vesicular mur- 
mur and rales sometimes temporarily suppressed, and reproduced 
suddenly by an act of coughing, as in cases of acute bronchitis. 



Secondary Bronchitis. 

Bronchitis, either acute or subacute, occurs as an intrinsic element 
in certain fevers, viz., typhus and typhoid, especially the latter, and 
rubeola. It may occur as a contingent element in other varieties 
of essential fevers. It becomes developed under circumstances 
which lead the pathologist to consider it one of the forms of the local 
expression of certain constitutional affections other than fever. It is 
regarded in this light when it coexists with gout, rheumatism, 
syphilis, scrofula, Bright's disease, etc. In all these instances the 
bronchitis is secondary to some general disease. It is liable, also, to 
be produced as a complication of different pulmonary diseases. Thus 
it is apt to accompany tuberculosis and pneumonitis, in these diseases 
differing from the idiopathic form in being frequently limited to one 
side, and even more circumscribed ; in other words, not preserving 
its symmetrical character. In the instances last cited, it is secondary 
to local affections. In this category may be included the frequent 
instances in which it occurs in connection with pertussis. In diseases 
of the heart it is often developed as a secondary affection. Questions 



S78 DISEASES OF THE EESPIEATORT OEGAXS. 

relating to the origin of the affection vthen thus secondarily produced, 
and other points of pathological interest, do not fall wirhin the scope 
of this work. Considered in a diagnostic point of view, the rarie- 
ties of secondary, as distinguished from idiopathic bronchitis, pre- 
sent peculiarities which are important. Some of these have been 
already incidentally noticed. Others will be eonyeniently referred 
to in treating of the diseases which remain to be considered. It does 
not, therefore, seem advisable to bestow upon the diagnosis of bron- 
chitis occurring secondarily special consideration, under a separate 
Lead. 

Bronchial or Pulmoxaet Catarrh. 

The term catarrh, originally applied to affections characterized by 
copious liquid secretion or flux, subsequently came to be used in an 
extended sense to embrace most of the inflammatory affections seated 
in the air-passages. Inflammation of the bronchial mucous membrane 
is more appropriately designated by the title hroncidth, but the term 
catarrh^ may be convemently retained to denote either a morbid state 
falling short of inflammation, or an extremely ndld grade of inflam- 
matory action. In this sense pulmonary or bronchial catarrh is 
illustrated by the disorder popularly known as a common cold. 

The pathological appearances, determined mainly by inference 
from those presented in analogous structures, accessible to view dur- 
ing life, are due simply to hyperaemia, consisting of redness and 
swelling. The mucous secretion is more or less increased and modi- 
fied. Serous exhalation occurs, constituting, when abundant, a 
variety of bronchorrhea. As thus defined, pulmonary or bronchial 
catarrh is a frequent sporadic and also an epidemic affection. In a 
certain proportion of the cases of influenza the local morbid condition 
of the air-passages is of this description, a condition allied to, and 
often eventuating in inflammation. The affection of the bronchial 
mucous membrane induced secondarily in the course of fevers, the 
typhus and typhoid fevers especially, in many, if not most instances, 
falls more properly under the denomination of catarrh than bron- 
chitis. 

Cases of pulmonary or bronchial catarrh may present auscultatory 
phenomena identical with those observed in ordinary bronchitis ; the 
contracted calibre of the tubes at certain points, and the presence of 
Berum or mucus, constituting the physical conditions requisite for the 



BRONCHIAL OR PULMONARY CATARRH. 379 

dry and bubbling rales. The discrimination between bronchitis and 
catarrh, is to be based on the local and general symptoms which de- 
note in the one case the existence, and in the other case the non-ex- 
istence of inflammation ; and inasmuch as the latter merges into the 
former so insensibly that it is not easy to define the exact line of 
demarcation dividing them, it is not always practicable to make the 
distinction clinically. The point, however, is not one of great prac- 
tical consequence. 

Limiting the attention to the diagnosis, exclusive of questions re- 
lating to etiology, pathological relations, &c., these few words com- 
prise all that need be said under the head of pulmonary or bronchial 
catarrh. 



CHAPTER II. 

DILATATION AND CONTRACTION OF THE BRONCHIAL TUBES- 
PERTUSSIS— ASTHMA. 

The affections named in the caption of this chapter, are those which, 
in addition to bronchitis and pulmonary catarrh, have their seat or 
special manifestations in the bronchial tubes. The two first, viz., 
dilatation and contraction, are lesions affecting the calibre of the 
tubes. Pertussis or hooping-cough is an infantile disorder, the pri- 
mary and prominent local symptoms of which pertain to the pulmo- 
nary air-passages. Asthma is characterized by phenomena which 
appear to be dependent on spasm of the bronchial muscles. 



Dilatation of the Bronchial Tubes.* 

Dilatation of the bronchise was scarcely known to pathologists 
prior to the researches of Laennec. The inference naturally drawn 
from this fact relative to the rare occurrence of the lesion is not alto- 
gether correct. The inattention paid to the condition of the bronchial 
tubes in autopsical examinations led to the existence of dilata- 
tion being often overlooked, and sometimes confounded with tuber- 
culous excavations. The same remark will apply in a great measure 
to examinations since the time of Laennec ; so that at the present 
moment it is not easy to determine very accurately the degree of 
its frequency. Grisolle estimates that in a very active hospital ser- 
vice an average of one or two cases will be likely to be met with 
annually. Generally, if not uniformly associated with bronchitis, it 
probably, in most instances, involves the latter affection in its produc- 
tion. The mode in which it is produced is an interesting point of 
pathological inquiry, admitting of extended discussion. But it would 
be a digression from the range of practical topics to which this work 

^ Called Bronchiectasis. This name is too formidable for common use, and I do not 
therefore adopt it. 



DILATATION OF THE BRONCHIAL TUBES. 381 

is limited, to indulge in more than a brief passing allusion to it. 
Laennec attributed the dilatation chiefly to mechanical distension of 
the bronchial parietes from the accumulation of mucus. This expla- 
nation is now generally deemed inadequate, and the accumulation is 
regarded as rather the effect than the cause of the dilatation. A 
morbid condition of the walls of the tubes, impairing their elasticity, 
and rendering them less resisting to dilating forces, is, probably, as 
first pointed out by Dr. Stokes, a pre-requisite, the result usually of 
prolonged inflammation. Hence, the lesion is one of the sequels of 
chronic bronchitis. With regard to the causes more immediately en- 
gaged, they are doubtless not in all cases the same. Extraordinary 
efforts of the respiratory organs, as in the violent paroxysms of cough- 
ing which occur in pertussis, may prove the efficient cause in some 
instances. Obstruction of a bronchus by the pressure of an enlarged 
bronchial gland, or other causes preventing the exit of air and mucus, 
may occasion sufficient distension behind the obstruction to lead to per- 
manent enlargement. But in the great majority of cases, there is reason 
to believe the dilatation depends on a prior morbid condition of the pul- 
monary parenchyma. Dr. Corrigan^has described a special affection ^ 
involving this lesion, consisting in a morbid deposit around the tubes, 
which assumes the characters of fibro-cellular texture, leading to atrophy 
and obliteration of the pulmonary cells, and, in some instances, even 
contraction of the entire lung. Under these circumstances, according 
to his views, two active forces are combined in producing bronchial 
dilatation. One is the pressure of the atmosphere from within the 
tubes in an outward direction, to fill the vacuum caused by the 
diminution of the bulk of the surrounding parenchyma. The other 
is the traction exerted on the bronchial walls in consequence of the 
adventitiousfibro-cellular deposit becoming attached to the longitudinal 
fibres of the tubes, so that dilatation in this way results from the shrink- 
ing of the surrounding tissue. The morbid condition supposed to induce 
the lesion in the manner just mentioned. Dr. Corrigan calls ciiThosis 
of the lung, from an apparent resemblance to the affection of the liver 
known by that title. The contraction of portions of lung incident to 
the tuberculous deposit, and still more to the cicatrization of cavities, 
may induce dilatation of the bronchial tubes, the walls expanding to 
compensate for the vacant space. More frequently, however, this 
result follows obliteration of more or less of the pulmonary cells from 
pneumonitis, and the compression to which they are subject in cases 

1 Dublin Medical Journal, May, 1838. 



382 DISEASES OF THE EESPIRATOEY ORGANS. 

of pleurisy. When the parietes of the chest do not readily collapse 
to fill the space left by the absorption of the intra-vesicular deposit 
in pneumonitiSj and the liquid effusion in pleuritis, the bronchial 
tubes, previously weakened by the process of inflammation, yield to 
the pressure of the inspired air. Under these circumstances what 
will be presently noticed as the uniform or cylindrical variety of 
dilatation occurs, affecting in some instances the tubes of an entire 
lobe or lung. Finally, according to Hope and Rokitansky, collapse 
of portions of the lung from obstruction of the lesser bronchial twigs in 
some cases of bronchitis, when the collapsed portions are situated at 
considerable depth in the lung, and near a larger bronchial tube, 
may give rise to dilatation, on the principle which plays the most 
important part in the production of the lesion in connection with 
most of the affections to which it is consecutive, viz., expansion from 
the pressure of the inspired air to fill a vacuum.^ 

With reference to the practice of physical exploration, dilatation 
of the bronchial tubes is a lesion of interest and importance, from its 
giving rise to signs which are liable to lead to errors of diagnosis. 

Following Laennec, subsequent writers have described three varie- 
ties of dilatation. One variety consists in a spherical, sacculated, or 
pouch-like dilatation, occurring usually in the third or fourth subdi- 
visions, forming, in effect, a cavity which may attain the size of 
a walnut, and according to Rokitansky, a hen's egg. A second 
variety, which is essentially similar, consists in a series of globular 
dilatations along the course of a tube, the calibre of the interme- 
diate portions retaining the normal size. The tube presents an 
appearance compared by Elliotson to a string of beads. In the 
third variety, a cylindrical and nearly uniform enlargement of a 
tube, with more or less of its branches, takes place. The last spe- 
cies of dilatation sometimes extends over a whole series of bronchial 
subdivisions, the enlargement gradually increasing toward their ex- 
tremities, ending abruptly in cul-de-sacs ; the appearance when laid 
open being not unlike that of the finger of a glove. Occasionally 
the several forms of dilatation are combined in the same lung. 

Bronchial dilatation associated with obliteration of the cells, and 
contraction of the pulmonary parenchyma, is attended with a corre- 

^ The reader desirous of a fuller exposition of the mechanism of the production of this 
lesion may consult with advantage the works on Pathological Anatomy by Hasse, Am. 
Ed. page 280, et seq. ; Jones and Sievekings, Am. Ed. page 389; and Rokitansky, Syd. 
Ed. vol. iv, page 5. 



DILATATION OF THE BRONCHIAL TUBES. 883 

sponding amount of diminution of tlie size of the chest, sometimes 
with displacement of the movable viscera. In all such instances, 
probably, the diminished bulk of the lung and consequent collapse of 
the thoracic parietes precede the dilatation. 

The surrounding pulmonary parenchyma is more or less condensed. 
This is necessarily, to some extent, a result of the pressure of the 
expanded portion of the tube ; but according to Corrigan, in a certain 
proportion of cases it is increased by the exudation of a solid material 
which preceded the dilatation. The dilated tubes contain puriform 
liquid in greater or less quantity. 

Cases have been observed in which several globular dilatations ex- 
isted near the apex of the lung, communicating by intervening bron- 
chise, so as to resemble closely a united group of excavations similar 
to those not unfrequently met with in subjects dead with tuberculous 
disease. Under these circumstances the lesion, on a superficial ex- 
amination, might readily be considered to have proceeded from 
phthisis. In the other forms, bronchial dilatation was formerly, as 
already remarked,^ confounded with phthisical cavities. On the other 
hand, in the opinion of a distinguished pathologist, many of the in- 
stances of the so-called cirrhosis of the lung are, in fact, cases of 
tuberculous cavities.^ 

The anatomical conditions sustaining proximate relations to the 
physical signs in cases of dilatation, are the degree and extent of 
the enlargement, and the particular form which it assumes ; the size of 
the bronchial tubes connected directly with the dilated portion, or 
portions ; the presence or absence of mucus, and its abundance when 
present ; the diminished bulk of the lung, partially or entire, and the 
consequent contraction of the thoracic walls. 

Physical Signs. — Dulness on percussion generally attends dilata- 
tion of the bronchial tubes. The dulness is due mainly to the con- 
densation and contraction of the parenchyma which accompany the 
dilatation, and it is marked and diffused in proportion to the degree 
and extent of the abnormal density which the lung acquires. The 
dulness may be somewhat increased at times by an accumulation 

* The test of cavities formed by bronchial dilatation, in doubtful cases, is the presence 
of the characters of the mucous membrane in the tissue lining the cavities, as determined 
by microscopical examination. 

2 Prof J. Hughes Bennett. I take the liberty of making this statement on the strength 
of a verbal expression of the opinion to the writer. See also. Treatise on the Pathology 
and Treatment of Pulmonary Tuberculosis. Edinburgh edition, pages 48 and 49. 



384 DISEASES OP THE EESPIBATOltY OUGAS-S. 

of mucus mtliiii tlie enlarged tubes. To tiie foregoing rule there air 
exceptions. Increased clearness of percussion-resonance is occasioi.- 
ally ol^serred, notwitlistanding tlie pTi3ino3iarypau:€SBch.jiB» sarroDndm" 
the enlarged tuhes is more or less condensed md ccmliaeled. This 
arises from the air Tuthin the tuhes bemg sdlcicait to OTerbalamee liie 
abnormal density of the lung. The resonance under these cirennastaiices 
becomes either purely tympanitic (tubular), or Te^eolo-t^paiiitic. 
The vesicular quality, in other words, is impaired cr logl^ and flie 
pitch raised. The resonance may even assiame an aa^lioiie diazacter. 
Increased clearness is of c : -_:y present wlaen the briMidiial 

tubes are free from morbid j_ ,^:..Li ; and as their ecmditiiHi in liiis 
respect Taries at different times, percussion mil elicit only at oeitain 
periods, a clear sound -which -will be found to alternate willi dnlm^ iJje 
latter being present when the tubes are more rr ^^^' ^^'ledwidi mocos. 

The physical conditions are more eminentiT :^ - . . '.le te the jao- 
duction of tubular or bronchial respiraliofn, when the tidies ane miob- 
strocted, proxided the diiaptatioii be of the ejlindiieal Taiielj. The 
enlai^ed calibre of the liroiichiss and t^ pafanonaiy eondensalim 
combine to render the respiratory soimd non-vesicTilar amd. blowing. 
The bronchial characters are strongly marked and die somid inteinse, 
ceteris paribu.s, in proportion to the enlargement and increaiBed dema:^. 
The difiusion of the tubular respiratioii wiH coixeBp*(Hid miUh. the ^ace 
over which the dilatation extends. 

The presence of mucus within the dilated tubes in greater or l^s 
abundance gives lise to moist brcndiial or bdbbling rales, oeeornng 
at irregular periods, and variable in loudn^s, as in ^m^ bron- 
chitis. A degree of coarseness approaching to gmgHng ■will be likelj 
to characterize these mneoi^ rales if tbe ealibre of tlie tubes be eon- 
siderably enlarged. 

The vocal resonance is generally exagg^^ted, and tHvndiophimj 
is often strongly marked- Vocal fremitus is incr^ised someiimes in 
a notable degree. An abnormal transmission of the heart-sounds 
may also be observed. 

The affection in some instances leads to dianges apparent on 
inspection. The condensation and contraction of the pafananazj 
parenchyma may be sufficient to canse depression of the chest over 
the site of the lesion, rarely, however, so great as obtaiiffi in some 
cases of advanced tuberculous disease. In the form of the dbea^ 
described by Corrigan, the diminished bulk of the lung leads to an 
obvious contraction of one side of the chest. 



DILATATION OP THE BRONCHIAL TUBES. 385 

In the sacculated or cystic variety of dilatation, provided the en- 
largement be considerable, there may be present the physical signs 
of a cavity, viz., the cavernous respiration, gurgling, and in some 
instances pectoriloquy. Even metallic tinkling was observed in a 
case reported by Dr. Barlow, of London.^ 

Diagnosis. — Thq diagnosis of dilatation of the bronchial tubes is fre- 
quently attended with extreme, and in some instances insurmountable 
difficulty, owing to the physical signs being similar and indeed identical 
with those incident to other forms of disease. The liability to error 
arising from the fact just stated, renders it important to bear in mind 
the diagnostic points by which this lesion is to be discriminated from 
affections involving analogous physical conditions, but differing widely 
in pathological features. 

Bronchial respiration, increased vocal resonance, bronchophony, 
and exaggerated fremitus, are signs which accompany the consoli- 
dation of lung incident to pneumonitis, and tuberculosis. With 
acute pneumonitis, dilatation of the tubes can hardly be confounded, 
except the attention be directed exclusively to the physical signs. 
The one is an acute, and the other eminently a chronic affection. As 
respects acute symptoms, a resemblance exists only when acute bron- 
chitis supervenes on bronchial dilatation. Under these circumstances 
the pulmonary symptoms will be those belonging to bronchitis, ex- 
clusive of the distinctive features of pneumonitis, viz., lancinating 
pains and the rusty or bloody expectoration. The characteristic 
auscultatory sign of pneumonitis, viz., the crepitant rale, is absent. 
Were the mistake to occur of attributing the combined phenomena 
of bronchial dilatation and acute bronchitis, to pneumonitis (which 
with due care should not be made), the progress of the disease would 
in a short time lead to a correction of the error, for the physical signs 
which were incorrectly supposed to denote inflammatory solidification 
are found to remain, and perhaps become more marked after the local 
and general symptoms of acute inflammation have disappeared. In 
pneumonitis, on the contrary, these signs cease to be observed, or at least 
are notably lessened, shortly after the symptoms denote resolution of 
the inflammation. From chronic pneumonitis the discrimination must 
be less easy. But chronic pneumonitis is an affection so rare that, prac- 
tically, the fact of its occasional occurrence may almost be disre- 
garded. When it occurs, it is generally preceded by the acute form of 

' Guy's Hospital Reports, 1847. 
2-3 



386 DISEASES OF THE RESPIRATORY ORGANS. 

the disease. If in a doubtful case tHe pre-existence of acute pneu- 
monitis be clearly determined, this constitutes an important diagnostic 
point. Moreover, chronic pneumonitis is accompanied by general 
symptoms indicative of a graver malady than simply bronchial dila- 
tation. The situation of the pulmonary affection, as indicated by the 
physical signs, is a point of importance. Pneumonitis in the great 
majority of cases attacks the inferior lobe ; bronchial dilatation in 
most instances is seated in the upper lobe. 

The difficulty of diagnosis relates chiefly to the discrimination of 
bronchial dilatation from tuberculous disease. Each of the tvro forms 
of dilatation, viz., the sacculated and cylindrical, furnishes signs 
which belong equally to difi'erent stages of phthisis. Bronchial re- 
spiration, bronchophony, increased vocal fremitus, which attend 
cylindrical dilatation, denote, under certain circumstances, the pre- 
sence of crude tubercle. Cavernous respiration and gurgling are the 
signs of an excavation in forty-nine of fifty cases tuberculous in its 
origin. The discrimination is to be based, not on intrinsic differences 
in the physical phenomena, but on circumstances incidental thereto, 
and on the symptoms. Reasoning from negative facts, we may 
arrive at the conclusion that the phenomena are due to bronchial 
dilatation, because the absence of coexisting evidence of tuberculous 
disease renders it probable that the latter disease may be excluded. 

The differential diagnosis involves different points, whether the 
dilatation be cylindrical or sacculated, but the physical signs being 
different in the two varieties, they claim separate consideration. 

Dilatation of the cylindrical variety may present, as just stated, a 
group of physical signs which, in connection with cough and expec- 
toration, may appear to indicate a tuberculous deposit. "What are 
the circumstances favoring the conclusion that these signs and symp- 
toms are due, not to tuberculous disease, but to dilatation of the tubes ? 
The situation of the physical signs, viz., the bronchial respiration and 
bronchophony, is an important point. A deposit of tubercle takes 
place, in the vast majority of cases, first at, or near the apex of the 
lung. The physical signs of tuberculous consolidation are therefore 
found at the summit of the chest, especially marked in the clavicular, 
supra-clavicular, and infra-clavicular regions. The phenomena due to 
bronchial dilatation, on the other hand, are oftener manifested over 
the middle portion of the chest, than at the summit. Taken in con- 
nection with other circumstances, this is a strong diagnostic point ; 
but it is to be borne in mind, that the rule with respect to the situa- 



DILATATION OF THE BRONCHIAL TUBES. 387 

tion of the tuberculous deposit is not without exceptions, so that this 
point, by itself, is bj no means sufficient for the diagnosis. 

More or less dulness on percussion, as has been seen, attends dila- 
tation, dependent on the degree and extent of the coexisting conden- 
sation. The bronchial respiration and bronchophony are due, in part, 
to the greater density of the pulmonary tissue, but more to the en- 
larged calibre of the tubes. In tuberculous disease, these phenomena 
proceed exclusively from the consolidation ; and, other things being 
equal, they are intense in proportion to the increased density of lung. 
Hence, in tuberculous disease, bronchial respiration and bronchophony 
are not observed in a notable degree without physical evidence of a 
considerable amount of consolidation being at the same time afforded 
by percussion. In dilatation, on the contrary, the enlargement of the 
calibre of the bronchial tubes may be considerable, and the conden- 
sation moderate or slight. Under these circumstances, the bronchial 
respiration and bronchophony may be strongly marked, while the 
percussion-resonance is but little impaired. A striking disproportion, 
then, between these auscultatory phenomena, and the evidence fur- 
nished by percussion of pulmonary solidification, authorizes, to say 
the least, a presumption in favor of dilatation. 

The point to which most importance is to be attached is the ab- 
sence of the rational evidence 't)f phthisis derived from the history 
and symptoms. In cases of dilatation, cough and expectoration gene- 
rally have existed for a long period. If the affection be tuberculous, 
certain events and results are to be expected, which, if the affection 
be dilatation, the case will not be likely to present. Among these 
events and results the most prominent are progressive and marked 
emaciation, loss of muscular strength, pallor of the countenance, 
haemoptysis, lancinating pains in the chest, diarrhoea, marked accele- 
ration of the pulse, hectic paroxysms, night perspiration, chronic 
laryngitis. If all these are absent, the fact favors the supposition of 
dilatation being the pathological change giving rise to physical phe- 
nomena which, associated with more or less of the symptomatic phe- 
nomena just enumerated, would denote unequivocally the existence of 
tuberculous disease. Occasionally, however, it happens in cases of 
phthisis, that nearly all these rational indications are wanting. 
Hence, under these circumstances it is not safe to decide positively 
from their absence that tuberculosis may be excluded. 

From this consideration of the differential diagnosis it will be justly 
inferred that it is extremely difficult to determine that certain phy- 



S88 DISEASES OF THE RESPIRATORY ORGANS. 

sical signs are due to cylindrical dilatation of tte bronchial tnbes, 
and not to tuberculous solidification. In fact, tbe discrimination can 
rarely be made with great positiyeness. This would be a serious 
impediment in the way of determining the existence of phthisis, were 
cases of dilatation of frequent occilrrence. Fortunately for diagnosis, 
although unfortunately for human life, the latter lesion is as rare as 
the former affection is common. And for this reason were the prac- 
titioner to disregard the fact that cases of dilatation are occasionally 
met with, and not attempt to make the discrimination in practice, the 
chances of a false diagnosis are small. 

Dilatation of the sacculated or cystic yariety, giying rise to cayer- 
nous signs, yiz., cayernous respiration, circumscribed mucous rales or 
gurgling, and in some instances pectoriloquy, haye occasionally led 
those most experienced and skilled in physical exploration into the 
error of inferring the existence of a tuberculous excayation. 

The situation of the cayity is an important point, for reasons 
already stated. 

Tuberculous excayations are generally surrounded with conside- 
rable solidification from the presence of crude tubercle. Hence the 
cayernous signs furnished by auscultation usually coexist with marked 
dulness on percussion. This is less uniformly true of cayities formed 
by dilatation of the bronchise. The presence of cayernous signs, there- 
fore, with slight dulness surrounding the site of the cayity, fayors 
the hypothesis of dilatation. The signs of cayities from dilatation 
may be unattended by any appreciable dulness on percussion. 
This was true of a case of bronchial dilatation, simulating phthisis, 
reported by Louis.' In the case referred to, an error of diagnosis is 
admitted by that conscientious and accomplished obseryer. In view 
of the law of phthisis by which the deposit almost uniformly takes 
place, first at, or near, the apex of the lung, if the percussion-reso- 
nance aboye the site of a cayity, in other words in the supra and infra- 
clayicular region on the same side, be found to be clear and vesicular, 
this, although by no means positiye proof against the existence of 
tuberculosis, since the law just stated is not inyariable, concurs with 
other circumstances to render the supposition of dilatation probable. 

Another point pertaining to the physical signs is applicable to 
both yarieties of dilatation, but to the present yariety more particu- 
larly. The dilatation is generally, or at least frequently, limited to 
one lung. A tuberculous deposit takes place first in one lung, and 

• Pv.echerches sur la Phtliisie. 



DILATATION OF THE BRONCHIAL TUBES. 389 

in the great majority of cases, shortly afterward in the other lung. 
In cases of phthisis, therefore, advanced to the stage of excavation, 
there may be expected to be present on both sides of the chest phy- 
sical signs of tuberculous disease. Now, if with the evidences of a 
cavity on one side, the other side yield no signs of disease, the fact 
favors the exclusion of tuberculosis. 

If a case has been under observation for a considerable period, the 
existence of tuberculosis is evidenced by the physical signs of excava- 
tion becoming developed where previously the signs had denoted 
solidification. This succession of physical phenomena does not 
belong, certainly to the same extent, to the history of dilatation. 
And with some qualification and occasional exceptions, the general 
rule, laid down by Stokes on this subject, probably holds good, viz. : 
*^ In phthisis, we have first dulness, and then cavity ; while in dilated 
tubes, we have first cavity, and then dulness." 

The persistency of the cavernous signs without material alteration 
for weeks, months, and even years, is another point pertaining to 
physical exploration, which has considerable diagnostic weight. A 
stationary condition after the stage of excavation in phthisis is reached, 
is possible, and occasionally occurs, but only as a rare exception to 
the general rule. 

A notable degree of flattening of the chest at the summit is strong 
evidence against dilatation, the depression thus limited in this afiec- 
tion never being strongly marked. 

The absence of the rational evidence of phthisis derived from the 
history and symptoms, applies with greater force to the discrimina- 
tion when the question relates to the presence of sacculated dilatation 
or phthisis advanced to excavation, for a longer duration of the tu- 
berculous disease, if it exist, is implied, and therefore the events and 
results characteristic of the latter affection are less likely to be 
wanting. A cavity without notable emaciation, loss of strength, 
pallor, haemoptysis, lancinating pains, recurring diarrhoea, frequency 
of pulse, hectic fever, night perspirations, or chronic laryngitis, but 
associated with more or less cough and expectoration of long dura- 
tion, may be attributed to dilatation with much confidence. In this 
statement it is of course understood that cavities from abscess, or 
circumscribed gangrene, are excluded. 

In connection with the subject of the differential diagnosis of dila- 
tation and tuberculosis, the fact is not to be lost sight of, that both 
may exist conjointly. As remarked by Walshe : " This compound 



800 DISEASES OF THE RESPIPuATORY ORGANS. 

state is, probably, beyond the reach of diagnosis." Dr. Bo^ditcV 
gives an instance of a youth Tvho consulted him five minutes after an 
attack of haemoptysis, stating that he had been quite well up to this 
occurrence, save that he was liable at times to a cough, and in early 
life had had severe pulmonary symptoms. Expecting to find few if 
any physical signs of disease, Dr. B. was surprised at discovering 
bronchial and cavernous respiration, with bronchophony and pectori- 
loquy, throughout the whole of the left lung. On this side there 
was a contraction as if from old pleurisy. Three months afterward 
death occurred from tubercles developed in the other lung, and the 
bronchise enormously dilated were found to fill up the major part of 
the lung over which had been heard the physical signs above men- 
tioned. The protective influence of dilatation against tubercle is 
illustrated in this instance, the deposit taking place in the lung free 
from that lesion. 

A case which recently came under my observation will serve to 
illustrate certain of the diagnostic points involved in the difi'erential 
diagnosis of dilatation and tuberculosis, and at the same time, the 
difficulty of discriminating with positiveness. The patient, aged 45, a 
blacksmith, had suffered from cough and expectoration for fifteen 
years. He stated that he had had several hemorrhages from the 
lungs. He had, however, continued to labor at his trade till within 
a few weeks, and was then interrupted not by an increase of his pul- 
monary symptoms, but by an affection of a testicle. He was not 
emaciated ; did not present the aspect of a tuberculous patient, and 
had recently gained in weight. Over the left chest the percussion- 
resonance was moderately dull, with a somewhat tympanitic quality. 
Over the upper and middle thirds, in front, of the left side, bronchial 
respiration was intense, the expiration notably prolonged, high in 
pitch, and metallic. Strong bronchophony coexisted, the voice 
seeming very near the ear. Whispered words were accompanied by a 
strong souffle, and transmitted to the ear with considerable distinctness 
(whispering pectoriloquy). The right side presented a well-evolved 
and perfectly normal vesicular respiration, with clear vesicular per- 
cussion-resonance. 

The history, symptoms, and signs in this case certainly point to 
dilatation. But the occurrence of haemoptysis renders it doubtful 
whether the case be not one of tuberculosis, presenting deviations 
from the usual course of that disease. I cite the case to show the 
uncertainty which must frequently attend the diagnosis. 

* Young Stethoscopist, second edition, page 104. 



CONTRACTION OF THE BRONCHIAL TUBES. 891 



SUMMARY OF THE MORE IMPORTANT OF THE DIAGNOSTIC CHARACTERS. 

The physical signs accompanying cylindrical dilatation, viz., bron- 
chial respiration, exaggerated vocal resonance, or bronchophony, 
and increased vocal fremitus, found to be persistent, and, unless acute 
bronchitis coexist, unattended by any of the signs and symptoms of 
acute pneumonitis. If acute bronchitis coexist, certain of the signs 
and symptoms distinctive of acute pneumonitis absent, viz., lancina- 
ting pains, bloody or rusty expectoration, and the crepitant rale. 
The bronchial respiration and bronchophony not diminished, and 
perhaps increased after the symptoms of acute bronchitis have dis- 
appeared. The previous history not showing the existence of prior 
acute pneumonitis, which is generally true of cases of chr-^nic pneu- 
monitis. The bronchial respiration and bronchophony oftener found 
over the upper than over the lower lobe. Frequently a disproportion 
between the auscultatory phenomena, and the evidence of solidifica- 
tion afforded by percussion. The general symptoms denoting a less 
grave affection than chronic pneumonitis. 

Contrasted with phthisis, the auscultatory phenomena, viz., bron- 
chial respiration, bronchophony, cavernous respiration, gurgling, and 
pectoriloquy, rarely found at the summit of the chest. Frequently, 
the dulness on percussion relatively to these auscultatory phenomena, 
proportionately less than in most cases of tuberculosis ; and in some 
instances no dulness existing, or the percussion-resonance clear at the 
summit. The physical signs when strongly marked and diffused over 
a considerable space, inclusive of the phenomena due to cavities, fre- 
quently limited to one side of the chest. The cavernous signs not 
preceded, but sometimes followed, by notable dulness on percussion. 
The physical phenomena persisting for a long period without any 
material alteration. Absence of the rational evidence of phthisis 
derived from the symptoms and effects of the latter affection, such as 
great emaciation, feebleness, anaemia, haemoptysis, sharp pleuritic 
pains, tuberculous fever, hectic, night perspirations, and chronic 
affection of the larynx. 



Contraction of the Bronchial Tubes. 

Abnormal diminution of the calibre of the bronchial tubes may be 
produced in different modes, and occurs in various pathological con- 
nections. It varies in extent, being sometimes limited to a small 



V 



392 DISEASES OF THE EESPIRATORY 0EGAX3. 



k 



space, and in other instances extending to considerable distance. Its 
situation may be near, or more or less remote from the primary bron- 
chus. In degree it is rariable. It may end in complete obliteration. 
Obliteration of the bronchial tubes, strictly considered, is a lesion dis- 
tinct from contraction. For practical pui-poses, however, it suffices to 
notice both under the head of contraction. As occuiTincr in connec- 
tion with the different varieties of bronchitis, contraction and even 
obliteration of bronchise have been already referred to. Exclusive 
of these connections, existing as permanent lesions, they are rare, 
and to determine their existence during life by signs and symptoms, 
in the great majority of instances is probably impossible. To the 
diagnostician they are interesting, chiefly in the light of disturbing 
elements, as it were, in physical exploration, giving rise to phe- 
nomena which may simulate other affections or modify their charac- 
ters, occasioning embarrassment if not error. 

The attention of pathologists was first called to the occasional oc- 
currence of permanent contraction and obliteration of the bronchial 
tubes by a French observer, M. Eeynaud, in 1835.^ Reynaud was 
led by his observations to the opinion that bronchial obliterations were 
not very uncommon. Hasse, however, suggests that he may not have 
distinguished in all instances between the simple obstruction produced 
by the presence of exudation of lymph in plastic bronchitis, and 
acute obliteration arising from organization of the exudation, or ad- 
hesion of the walls of the tubes. As described by Reynaud, and 
others, contraction and obliteration may be continuous, extending 
either over a single tube or a series, and sometimes all the tubes of a 
lobe, which is compared by Prof. Gross, to continuous stricture of the 
urethra, or the tubes may be narrowed or closed at one or more points, 
as if a ligature had been applied.^ 

The obstruction incident to obliteration, or a considerable degree 
of contraction, induces other physical changes in the pulmonary 
organs. Dilatation of the tubes, forming either a pouch-like cavity 
just before the point of the obstruction, or an enlargement, extending 
more or less along the tube leading to that point, is apt to follow. 
Beyond the contracted or obliterated tubes, the pulmonary lobules 
dependent thereon for their supply of air, become atrophied, shrivelled, 
or collapsed. And in consequence of the effect just mentioned, sur- 

» Mem. de TAcademie Roy. de Med. vol. iv. 1S35. 

2 These two varieties are described and figured la Gross's Pathological Anatomy, to 
which the reader is referred. 



CONTRACTION OF THE BRONCHIAL TUBES. 893 

rounding lobules are likely to take on an abnormal increase of bulk, 
becoming, in other words, emphysematous. This compound state 
defies diagnosis. 

It is obvious, that the extent of the consecutive pulmonary changes, 
together with the symptoms and signs, will depend on the size of the 
bronchial tube, or tubes, which are contracted or obliterated, as well 
as on the amount of obstruction, provided complete occlusion does 
not exist. Continuous obliteration affects usually the smaller divi- 
sions of the bronchise. Contraction or obliteration limited to a small 
portion of the tube, is observed principally in bronchise of the second 
or third order.^ Obstruction more or less complete, however, has been 
met with at different situations between the bronchi and the minute 
ramifications. Seated in a primary division of the bronchi, or, if 
the contraction or obliteration be continuous, extending over all the 
tubes of an entire lobe, the functions of the lobe will, of course, be 
interrupted or suspended, according as the supply of air is more or 
less diminished or cut off. The atrophy and collapse of the lobe 
which ensue are proportionate to the obstruction. These results will 
be less extensive, of course, in proportion as the obstruction is limited 
to the smaller tubes. 

The immediate local causes of diminished calibre of the tubes, and 
obliteration, are either situated within or exterior to the bronchige. 
Within the tubes, they consist of plastic exudation upon the mucous 
surface ; a tuberculous deposit, occurring at the same time within the 
vesicles ; hypertrophy of the mucous membrane ; morbid excrescences 
springing therefrom ; contraction from cicatrized ulcers ; foreign 
substances received from without, and solid morbid products, viz., 
calcareous formations, melanotic cysts, or acephalocysts gaining en- 
trance into the tube from within. In the list of causes seated in the 
interior of the tube are also to be included submucous deposits of 
serum, or lymph, carcinomatous matter, etc. The causes situated 
exteriorly act by producing pressure on the tube, or tubes. Among 
the numerous causes embraced in this class are enlarged bronchial 
glands ; masses of tubercle ; aneurismal or other tumors ; and pleuritic 
effusions. Several cases were reported some years ago by Mr. T. 
W. King, of London^, in which pressure of the left auricle, in connec- 
tion with enlargement of the heart, was found to have occasioned 

» Gross's Path. Anat. page 419. 

"^ Guy's Hospital Reports, April, 1838. For summary, see Gross's Path. Anat., page 
420. 



394 DISEASES OF THE RESPIRATORY ORGANS. 

considerable fiattening of the left bronchus, reducing its calibre suffi- 
ciently to produce partial obstruction. From the foregoing enume- 
ration, it is evident that, as already stated, the pathological relations 
of contraction and obliteration of the tubes are various. 

That these lesions give rise to important symptoms and signs is 
certain. Embarrassment of respiration, manifested by dyspnoea, 
may accompany cases in which the obstruction is seated in a bronchial 
tube of large size, more especially "when the obstruction is rapidly 
induced, and if it occur in connection with some other affection which 
compromises the pulmonary functions. Nothing, however, pertaining 
to the embarrassment of respiration would indicate specially these 
lesions. The signs, theoretically determined, are dulness on percus- 
sion in proportion to the number of pulmonary lobules shrivelled or 
collapsed, provided emphysematous dilatation of the surrounding 
cells be not sufficient to compensate for the condensation. In the 
latter case the clearness may be preserved, with perhaps a vesiculo- 
tympanitic quality. Both conditions, i. e. the collapse of certain 
lobules, and the over-distension of others, combine to render the 
respiratory murmur feeble or inaudible. The phenomena incident 
to bronchial dilatation may coexist, and supersede those due directly 
to the contraction or obliteration of the tubes. In like manner the 
signs belonging to the latter may be lost among those to which the 
various associated morbid conditions give rise. If the situation and 
degree of the obstruction be such as to occasion collapse, more or 
less complete, of an entire lobe, depression of the thoracic walls will 
follow. This, as well as the other signs, will be likely to be presented 
over the superior and middle thirds in front, owing to the fact that 
the lesions have been oftener found in the upper than in the lower 
pulmonary lobes. 

Finally, to determine positively the existence of these lesions during 
life, as already stated, is not to be expected in the great majority of 
instance?. The coexistence of feebleness or absence of respiratory 
sound, with dulness and perhaps depression, under circumstances 
when this combination of signs is not otherwise explicable, points to 
obstruction of a large bronchial tube, and this opinion may sometimes 
be formed with considerable confidence. The grounds for this opinion 
are less in proportion as the contraction and obliteration are limited. 
The same combination of signs, situated elsewhere than at the sum- 
mit of the chest, warrants a suspicion of the existence of these lesions. 
This suspicion may be indulged the more if the patient have suffered 



PERTUSSIS — HOOPING-COUGH. 395 

from chronic bronchitis ; and still more if plastic exudation, in the 
form of bronchial moulds, or if calculi, have been expectorated. Situ- 
ated at the summit of the chest, these signs would be considered to 
denote a tuberculous deposit ; and, it is not improbable, as intimated 
by Stokes, that in a certain proportion of the instances in which a 
false diagnosis of phthisis is made, the physician is misled by the 
phenomena due to permanent obstruction of bronchise. Fortunately 
for diagnosis, the lesions are extremely rare. 



Pertussis — Hooping-Cough. 

The seat of hooping-cough is indeterminate ; but its primary and 
prominent symptoms appear to depend on a morbid condition of the 
bronchial tubes. Nosologically, it may properly enough be classed 
among neurotic affections, and like the other neuroses it is devoid of 
any appreciable anatomical characters. The morbid appearances 
found after death do not belong intrinsically to the disease, but are 
due to its complications, independently of which it very rarely, if ever, 
proves fatal. The most frequent comj)lications are bronchitis and 
pneumonitis. Others less common, are tuberculosis, croup, pleuritis, 
enteritis, and convulsions. I have observed abdominal tympanitis 
irrespective of any other apparent intestinal complication, a symptom 
mentioned by M. Blache, as incident to this affection. 

Bronchial dilatation and pulmonary emphysema are occasional 
sequels of hooping-cough, the latter, according to Rilliet and Barthez, 
much less frequently than is generally supposed. External em- 
physema of the areolar tissue from rupture of the lungs, has been 
known to be produced by the violence of the cough. 

Physical Signs and Diagnosis. — There are no physical signs 
characteristic of hooping-cough. During the catarrhal period, the 
bronchial rales incident to catarrh and mild bronchitis may be heard, 
and also, more or less, during the continuance of the disease. These, 
of course, only show the coexisting irritation or inflammation of the 
mucous membrane. During the paroxysms, the series of expiratory 
efforts exhaust the quantity of air in the pulmonary cells, sufficiently 
to produce an appreciable diminution of the percussion-resonance ; 
and during the prolonged hooping inspiration, the expansion of the 
cells is unaccompanied by an audible vesicular murmur. The latter 



mSEASMS Ol" IE3 EESPIRATOET 0RG-A:N"S. 

M fS:Qhaiilj o~-.ir :: r^ .:.::: :z. — :_t : ilnrnn of air caused bv ihe 
cantEaelio>ii at z'l- -:. : 

The din ZL : L . i ^- - : : : _■ _ li to be ba^d on the symptoms 

--■": !';"- .: :'-- u_-c^ic. li^ese are so striking and disdnetiye that; 
_ T : 1 : : t 1 in tke great majority of cases witiicjot ^Seohy after 
tl 7 ._ - . : :-de traits become derdoped. Ihirmg the eatarrLal 
;: - : " . - ; ? r : ~~ ' - - - r ~:l enee of tte congk in. comparison with 
:_T _ :- _: _ — -7 ;7_^: : ^ : ::s abruptness and paroxysmal charac- 
tgTy witii more or less of the peculiarities wMcK are afkemaid sopromi- 
E.e~:. ^:-:i:-': ;: :'- '^ : ' "lie diagnosis: "bnt witHout the 

c~ : : - : -i: . , „: : . r lying upon the description giTen 

'7-7- . : :- :;: r L .: a loss to form a positive opinion 

:.- _ I „ - i: ': : stage. At this period, 

:^ „ 1. :_--r _i _;:^j _ . _ :^ _- -iiz.:;-, except what sometimes 
L: _ :le symptoms are so extremely mild, that the special cha- 

Cases of tins kind are, howeyer, ex- 

:. 7i_ 7.7 - - ^_ .._.^.:o. :..c ^cctLan is kss readfly recognized from 

: L T : : : - 1 : the hoofmig inspiralicm is less nniformly present. 

ir in&eqoaifij of eases 6i ibe disease in adults, it 

- r - y^oTLf because the poaaiiMlitj of its existaKe may not 

- _:D.d of the phj^eian. 

Physica. - -don may famish osefiil information concerning 

- T™-;!: : ■ -. 1 are liable to beeome developed in the eoorse of 

: _ T I „ ;:.n^eiice of Ae dij and bubbliog imks during the 

: 1 " . „ : etwecn iflie parfngr^ns of congMng, shows the coexis- 

-tI - 1 ;--- --^. by thdr character, tZ^t--. -"i situation, the 

:o judge of the nr_ 1 r . ;._ '. y.ie of the tubes 
1 . 7: of primary bronchial inflammation. Xegatively 

" :. 7 : ~ - ' : \ signSj or the ": . ^ ^ : : ^ : .-Ij of those belonging 

.; :.~. .7 ._ : zrtanty in de: 7. „__._: ^- :'_e non-existence of 

other and more ^: : ilications, viz., pneumonitis, tuberculosis, 

pleurilis, and anpL^ 7 _ 7": r esistenee of any one or more of the 
corapifieatiQiiis jnsi :i _ 7 1 . - : be det^mined by means of the phy- 
aaeaH evidssce cf tikeir presence, taken in connection with vital phe- 
nomeiia. Bat inasii: 1 - -1^ 7-zttosa of these several affections 
inBl be <:Gii^deied :__- _-_7 y^: iid the points involved in their 
feerjunnmation w(hen they ar 7 to hoaping-coDgh are essen- 

tiallj the same as when they aie pjdiaary, it would ia^ : 7 e'iless 

airtJcipation of fkture topics to treat of their symptonii :._:. i^.-ns in 
this connection. 



ASTHMA. 397 



Asthma. 



The term asthma, formerly applied to dyspnoea, occurring as a symp- 
tom of different diseases of the organs of respiration and the circulation, 
is now restricted to a paroxysmal affection, the primary local mani- 
festations of which consist in spasmodic contraction of the circular 
muscular fibres of the smaller bronchial tubes. Like the affection 
last considered (hooping-cough), it belongs, nosologically, among the 
neuroses, and is consequently wanting in appreciable anatomical 
characters. Although not a very rare form of disease, it is very rarely 
met with in practice as a purely neurotic affection ; in other words, 
in a large proportion of cases it is associated with morbid conditions 
other than spasm, to which it stands in the relation either of cause 
or effect. Its existence, however, independently of other affections, 
is sufficiently established. 

Physieal Signs. — The physical signs during the paroxysms of 
asthma are not in a positive sense distinctive. Exploration of the 
chest is useful chiefly in a negative point of view, enabling the prac- 
titioner to exclude other affections accompanied by dyspnoea, and 
also to detect complications. Percussion elicits clearness of resonance. 
From the very frequent coexistence of emphysema, the percussion- 
resonance, in the majority of cases, is clearer than in health, with, 
perhaps, more or less tympanitic modification. If emphysema be not 
present, the volume of the lungs may be reduced by the expiratory 
efforts so as to diminish appreciably the clearness on percussion.^ 
Owing to the obstruction to the entrance of air into the cells, the 
lungs may not expand readily to fill the vacuum caused by the en- 
largement of the chest by inspiration. Hence, the pressure of the 
atmosphere occasions obvious retraction of the epigastrium, the 
thoracic walls of the lower part of the chest in front, and sometimes 
depression above and below the clavicles, w^ith the inspiratory acts. 
The vesicular murmur is scarcely or not at all appreciable, and is 
replaced by sibilant and sonorous rales, commingled in varied and 
constantly varying proportions, the former generally predominant 
with inspiration. The dry rales also accompany the act of expiration ; 
the sonorous oftener predominating during this act. The rales with 

' Walshe, op. cit. 



398 DISEASES OF THE RESPIRATORY ORGANS. 

inspiration frequently merge into those attending expiration, so that 
they appear to be continuous. They are diffused extensively over the 
chest on both sides, and the sounds are generally loud and diversified, 
whistling, chirping, cooing, snoring, etc., in alternation, or heard 
simultaneously in different portions of the chest. The moist or bub- 
bling rales are rarely present during the severity of the paroxysm : 
but may be observed toward its close, at the time when expectoration 
is apt to occur. After the paroxysm, bronchial rales generally con- 
tinue to be heard for several days, and finally cease, provided the 
patient does not labor under a persisting chronic bronchitis. 

Diagnosis. — The diagnosis of asthma rests on the occurrence of 
paroxysms of difficult respiration, presenting the physical phenomena 
just described, and the exclusion of other affections which may give 
rise to paroxysmal dyspnoea, resembling more or less that originating 
from spasm of the bronchial muscles. 

In a child, an attack of asthma may, at first, excite suspicions of 
croup. But a little examination suffices to show that the obstruction 
is not seated at the larynx. The absence of the striking characters 
pertaining to the voice and cough, when the aperture of the glottis is 
diminished, whether it be from exudation or spasm, warrants the ex- 
clusion of croup, and also laryngismus. From the infrequency of 
cases of asthma in childhood, the disease is not expected, and hence, 
when it does occur, other affections more common in early life are 
suspected until the diagnosis is settled. In the adult, laryngeal affec- 
tions, accompanied by difficult respiration, viz., oedema glottidis, 
acute laryngitis, and occasionally spasm of the glottis, are referred 
to their true situation with still greater facility than in the child. In 
addition to the circumstances just mentioned, which are equally ap- 
plicable, the patient's sensations indicate correctly the seat of the 
obstruction. 

Difficulty of breathing, occurring in paroxysms, is incident, in cer- 
tain cases, to disease of heart, giving rise to what has been known 
by the name of cardiac asthma. The existence of heart disease may 
be positively ascertained by means of physical signs. It is true that 
dilatation of the heart occurs as a complication of asthma ; but under 
these circumstances the asthma is known to have existed for a long 
time, and is generally, if not ahvays, associated with emphysema. 
The dyspnoea occasioned by embarrassment of the pulmonary circu- 
lation differs in several obvious particulars from that caused by ob- 



ASTHMA. 399 

struction of the smaller bronchial tubes. It is accompanied by 
palpitation, by marked irregularity in the heart's action, by a sense 
of distress referred to the prsecordia, and a feeling of impending dis- 
solution. The thoracic walls do not contract with inspiration, and 
the dry bronchial rales are either absent, or do not exist in that 
degree which characterizes an attack of asthma. Disease of heart, 
occasioning intense paroxysmal dyspnoea, generally produces more or 
less habitual difficulty of breathing, or at least dyspnoea is frequently 
excited by slight causes, such as exercise, etc. 

Angina pectoris, which may involve intense dyspnoea, is attended 
by other symptoms so distinctive that it is not readily confounded 
with asthma. 

Acute bronchitis, occurring in a person affected with emphysema, 
may give rise to great dyspnoea. Under these circumstances, bron- 
chial spasm is frequently a contingent element of the disease. The 
paroxysmal increase of the dyspnoea generally depends on this ele- 
ment. But, in so far as the difficulty of respiration proceeds from 
the bronchitis in combination with the emphysema, irrespective of 
spasm, it is more persisting than in cases of pure asthma. It pursues 
a course corresponding to that of the bronchial inflammation, being 
developed less suddenly than when due to spasm alone, continuing 
during the stationary period of the inflammatory condition of the 
membrane, and disappearing gradually in proportion as resolution of 
the bronchitis takes place. It is accompanied with more cough and 
expectoration than belong usually to pure asthma, and the matter 
expectorated presents the characters of mucous inflammation. The 
moist bronchial rales are more likely to be present than in cases of 
pure asthma. The existence of the emphysema ' is' ascertained by 
means of its characteristic signs, which are hereafter to be consi- 
dered. 

The dyspnoea, which forms the most prominent symptom in capil- 
lary bronchitis, on a superficial examination, might, for a time, lead 
the practitioner into the error of supposing the case to be simply an 
attack of asthma. But a proper investigation should speedily correct 
this error. Capillary bronchitis generally succeeds, or is coincident 
with, inflammation affecting the larger bronchial tubes. The local 
symptoms of bronchitis are present, viz., cough, expectoration of 
mucus more or less modified, and substernal soreness. The respira- 
tions are more frequent. Great acceleration of the pulse is a dis- 



400 DISEASES OF THE RESPIRATORY ORGANS. 

tinctive feature. The mucous and the sub-crepitant rales are dis- 
covered on auscultation. The dyspnoea and associated symptoms are 
persistent, increasing until the inflammation reaches its acme, and 
slowly diminishing as the inflammatory condition subsides, presenting 
thus, in its course, a striking contrast to an asthmatic paroxysm. In 
capillary bronchitis, as in ordinary bronchial inflammation combined 
with emphysema, the dyspnoea may present exacerbations which are 
due to spasm ; but the spasm is only an incidental element of the 
afiection, not, as in pure asthma, the primary, and in relation to the 
bronchial obstruction, the sole pathological condition. 

In conclusion, the diagnosis of asthma, in most cases, is very easily 
made. The fact of its existence is generally well known in the cases 
which the physician meets with in practice, repeated attacks having 
been already experienced. It is only when few or no paroxysms 
have previously occurred that there is room for momentary doubt, 
and, in such cases, the distinctive symptomatic characters, taken in 
connection with the absence of the physical evidence of other affec- 
tions giving rise to embarrassment of respiration, suflice for a prompt 
and positive discrimination. 

As already remarked, instances of simple, uncomplicated asthma 
are exceedingly rare. Disconnected from even catarrh (dry asthma), 
and consisting of pure spasm, the aff'ection is to be classed among 
the curiosities of clinical experience. In most cases of confirmed 
asthma, the practitioner may expect to discover emphysema, and in 
a certain proportion of cases, disease of heart. The existence or 
non-existence of these aff"ections is to be determined by the presence 
or absence of their diagnostic symptoms and signs. 

SUMMARY or PHYSICAL SIGNS BELONGING TO ASTHMA. 

Clear percussion-resonance. Retraction of the base of the chest 
in front and the epigastrium in the act of inspiration. Vesicular 
murmur enfeebled or abolished. Sibilant and sonorous rales, with both 
respiratory acts, loud and diversified, extensively diff'used over the 
chest. Moist rales, in some cases, at the close of the paroxysm. 



CHAPTER III. 



PNEUMONITIS— IMPERFECT EXPANSION (ATELECTASIS) AND 

COLLAPSE. 



Pneumonitis, or inflammation of the pulmonary parenchyma, one 
of the most interesting and important of the diseases affecting the 
respiratory organs, occurs under three forms, viz., 1. Lobar pneumo- 
nitis, the ordinary form of the acute disease in the adult ; 2. Lobular 
pneumonitis, a form peculiar to children ; and 3. Chronic pneumo- 
nitis. This division is of practical importance, and each form claims 
separate consideration. Varieties based on other circumstances, such 
as the situation and extent of the inflammation, its occurrence as a 
primary, secondary, or intercurrent affection, etc., will be noticed in- 
cidentally so far as is consistent with the scope of this work. Under 
the head of Lobular Pneumonitis, I shall notice certain morbid con- 
ditions which have been hitherto generally considered to belong to 
that variety of the disease, and which, at present, are most conveni- 
ently arranged in the same nosological category, viz., imperfect ex- 
pansion of more or less of the pulmonary lobules after birth (atelecta- 
sis), and collapse. 



Acute Lobar Pneumonitis. 

The ordinary form of acute pneumonitis in the adult is called 
lohar, in contradistinction to lobular pneumonitis, the form peculiar 
to children. The appellation imports that the inflammation is diffused 
over an entire lobe of the lungs. This is true, at least in the vast 
majority of cases, provided the pneumonitis be primary. Secondary or 
intercurrent pneumonitis may be more circumscribed. Primary lobar 
pneumonitis is of frequent occurrence. Secondarily the disease 
is often associated with periodical, continued, eruptive, puerperal 

26 



402 DISEASES OF THE RESPIEATOEY ORGANS. 

and rheumatic fevers, and with, purulent infection of the blood. It 
is developed also as a complication of croup, hooping-congh, acute 
affections of the heart, encephalon, etc. In these various pathological 
connections, the vital phenomena, or symptoms, are presented vrith 
additions and modifications which serve to enhance the importance of 
the physical signs in the diagnosis of the disease. 

Authors make several varieties of primary lobar pneumonitis, 
based mainly on semeiological distinctions. So far as relates to diag- 
nosis, it will suffice merely to enumerate the varieties generally re- 
cognized. 

If the phenomena of the disease indicate purely an acute inflamma- 
tion unattended by any unusual features, it is frequently styled /ranA' 
pneumonitis. A better title is simple acute pneumonitis. 

Accompanied by a marked degree of prostration, and more espe- 
cially with passive or low delirium, it is called typhoid pneumonitis. 
Primitive pneumonitis may present these characters, but it is proba- 
ble that typhoid and typhous fevers, complicated with inflammation 
of the lungs, are sometimes confounded with pneumonitis presenting 
what are ordinarily known as typhoid symptoms. 

Occurrins; in combination with general bronchitis or catarrh, which 
is apt to be the case, more especially when the latter affections pre- 
yail epidemically, constituting influenza, the disease has been dis- 
tinguished as catarrhal pneumonitis. 

When it follows a wound, or some external injury, it is traumatic 
pneumonitis. 

The term bilious, applied in an indefinite sense to various affections, 
is frequently used in connection with this disease. In its application 
to cases complicated with icterus it has an obvious significance, 
which is less apparent when it is extended to cases in which the only 
evidence of disordered function of the liver are sallowness of the 
complexion, a greenish or yellow coating of the tongue, dulness of the 
intellect, and a sense of uneasiness in the epigastrium. In districts 
known as miasmatic, the disease is called bilious pneumonitis, and it 
is often combined, in these localities, with the phenomena of the peri- 
odical fevers. 

Pneumonitis is called latent, as already stated, when it exists 
without the local vital manifestations which are usually present. So 
far as diagnostic symptoms are concerned, it is sometimes remarkably 
latent ; but under these circumstances it is rarely the case that the 



ACUTE LOBAR PNEUMONITIS. 403 

existence of tlie disease may not be ascertained by means of the 
evidence derived from physical exploration. 

In a large proportion of cases, lobar pneumonitis is confined to one 
side of the chest. In a certain proportion of cases, however, the in- 
flammation affects both sides. This constitutes a variety called 
double pneumonitis. When confined to one side, usually a single 
lobe only is affected, but not very infrequently the inflammation extends 
over the whole of one lung. This might properly enough be con- 
sidered a variety of the disease, but it has no distinctive appellation. 

The foregoing varieties of pneumonitis, it will be observed, relate 
to the disease occurring as a primitive affection. It is developed, as 
already stated, in the course of numerous diseases. Occurring thus 
secondarily, it is often wanting in diagnostic symptoms, or they are 
masked by the phenomena of the disease of which it is a complication, 
so that without the aid of physical signs it would frequently escape 
detection. 

Following Laennec, pathologists agree in describing a series of 
anatomical cha-nges in acute pneumonitis belonging to three different 
periods. The career of the disease is divided into stages correspond- 
ing to these periods, and each stage or period, during life is charac- 
terized by phenomena, vital and physical, which are more or less 
distinctive. The first period constitutes the stage of inflammatoi^y 
engorgement ; the second, the stage oi solidification, or red hepatiza- 
tion ; the third, the suppurative period, stage of purulent infiltration, 
or gray hepatization. For a detailed description of the anatomical 
characters belonging to these different stages, the reader is referred 
to works which treat of the morbid anatomy of the affection. 

The essential anatomical characters which are particularly in- 
volved in the production of the physical signs belonging to the 
disease, are the following. First stage. Increased density from 
engorgement, and the presence of a viscid fluid within the vesicles, 
which are, as yet, not closed to the entrance of air ; co-existing 
pleuritis. Second stage. Solidification in consequence of closure 
of the greater part of the vesicles of the affected portion of lung 
by morbid exudation ; increased volume of the affected lung, and 
its incapacity for collapsing in expiration. Exudation of fibrin 
on the pleura, with more or less liquid effusion within the pleural 
sac. Third stage. Puriform fluid escaping from the cells into the 
bronchial tubes in greater or less abundance ; persisting solidification ; 



in some exses foniiati<iii of coMectioiis of purifomi matter resulting in 
esfities. 

PT^smd Sigim. — ^The sexeral methods of e:sploratioi3, with, the 
^^e exeeption of snecnseoiL, may all fiimish morbid phenomena in 
cases of lobar pneomonitas. The physical signs pertaining to the 
digeaise are therefore nnmerons ; bnt it mil be seen ihat as regards 
partiealar phenomena and their combinations, nniformitj in the dif- 
ferent stages of the disease and in the same stage in different ca,ses 
does not exist. This irant of constancy, howeTer, is rarely the eonrce 
of mndi difficnllty in the way of diagnoes, although it renders an 
acquaintance mth the Yariations which sse liable to occnr, in a prac- 
tical point of Tiew, highly important. 

The peren^on-resonance, in the first stage, or stage of engorge- 
ment; may be diminished ; in other words, the sonnd over the affected 
lobe, compared with that elicited in corr^ponding points on the un- 
affected side, is more or l^s dnlL This statement accords mth the 
views of most practical writers, bnt an opposite opinion is held by 
Skoda. He maintains that the percnsdon-sonnd r^nains unaltered, 
be the engorgement ever so great, prior to esndalion. This was, in 
feet, ike opinion of Laennec. Inasmuch as a &tal result very rarely 
occms in the stage of engorgement, opportnnifies to demonstrate the 
incorrectness of this opinion, are seldom offered. An instance has 
fallen nnder my observation, in which, owing to the disease e::,_* 
developed in a padent affected with great enlargement of ~ 
death took place before the local dianges, as proved by the ^ i: ; it. 
had advanced to ldie second stage. In this case, which has heen 
alreac^ referred to,' the limits of the affected lobe (the lower lobe of 
the light limg) were easily defined by dnlne^ on percossion, toge- 
ther with the presence of the crepitant rale. In general, however, it 
is probably tnie that if the resonance be diminished, in a marlie : 
degree, it is to be predicated that the exndalitm of solid matter his 
occurred, a result which it is to be borne in mind may follow eTtn 
within a few hours &Qm the first appearance of local symptoms of 
the disease. In proportion as the solidification becomes more and 
more complete, the normal resonance pn^r^sively diminishes. 
Other thin^ being eqnal, the lo^ of vesicnlar r^onance is a mea- 
sure of thr m ir.: :f - liiification. The ve^cnlar r^onance may, 
in feet, be i : :_^_t 1 : : : it is rarely the case that absolute flatness 

3 Tide aasjte, pag« 104. 



ACUTE LOBAE PNEUMONITIS. 405 

exists. If a certain proportion of the air-vesicles of the affected 
lobe do not still contain air, the bronchial tubes are never completely 
filled with morbid products. The quantity of air which the latter 
contain is sufficient to prevent total extinction of sonorousness. In 
this respect the loss of resonance in cases of solidification differs 
from that which frequently attends large pleural effusions. In the 
latter the abolition of sonorousness, in other words absolute flatness, 
is much oftener observed. 

In proportion as the density of the pulmonary parenchyma is in- 
creased, first by engorgement, and next by solid exudation, the sense 
of resistance felt in percussing over the affected lobe is greater 
than in corresponding situations on the healthy side of the chest. 
This sign' exists in a marked degree in the second stage of pneumo- 
nitis, and constitutes a means by which, to some extent, the amount 
of solidification may be estimated. 

The resolution of the inflammation is accompanied by a return of 
the vesicular resonance, and the normal elasticity. Percussion, thus, 
enables us to determine the progress made in the removal of the 
solid deposit, and the completeness of the final restoration of the 
affected portion of the pulmonary organs. 

The acoustic phenomena elicited by percussion wdiich have just 
been mentioned, relate mainly to vesicular resonance. The effects 
on the sonorousness of the chest, which may be produced by the 
anatomical changes in pneumonitis, are not fully embraced in the 
foregoing description. Over lung completely solidified by intra- 
vesicular deposit, whatever sonorousness remains must, of course, be 
non-vesicular, and consequently tympanitic. Exclusive of the rare 
instances in which, under these circumstances, there exists absolute 
flatness, the vesicular is replaced by a tympanitic resonance, which 
may be more or less marked. The term tympanitic expressing an 
abnormal quality of sound, irrespective of its intensity, the resonance 
may be in a marked degree diminished, and, indeed, but feebly 
appreciable, while its non-vesicular character is yet sufficiently appa- 
rent. In the second stage of pneumonitis, then, if there be not total 
extinction of sonorousness, in connection with a greater or less 
amount of dulness on percussion, a tympanitic resonance will be 
observed. 

In some instances the vesicular resonance is replaced by a strongly 
marked tympanitic sound. In intensity and clearness, the sonorous- 
ness over the solidified lung may even exceed the resonance on the 



406 DISEASES OF THE RESPIEATORY ORaAXS. 

unaffected side. Its non-vesicular ciiaracter and Mgliness of pitcli 
are the more striking, contrasted with the normal resonance, in pro- 
portion to its intensity. The sense of resistance on percussion, or 
pressure, in addition to other circumstances, serves to distinguish the 
tympanitic resonance occurring over solidified lung, from that inci- 
dent to some cases of emphysema, and from all cases of pneumo-hjdro- 
thorax, the thoracic parietes retaining theii' elasticity in the latter 
forms of disease. In cases of pneumonitis affecting the left lung, a 
tympanitic resonance may be due to distension of the stomach 
with gas. This source is often sufficiently evidenced by the gastric 
character of the sound, viz., notable acuteness of pitch, and a 
metallic quality. In some instances in which the upper as well as 
lower lobe is solidified, the gastric note is manifested at the inferior 
portion of the chest, while over the superior part the tympanitic reso- 
nance is lower in pitch and without any metallic tone ; and a tympa- 
nitic resonance, in cases of pneumonitis affecting the entire left lung, 
may be marked over the upper and middle portions, while flatness 
exists at the base. On the right side a tympanitic resonance may 
be transmitted from the distended colon ; but it is observed over the 
superior and middle thirds on this side, in cases in which below the 
upper boundary of the liver percussion elicits a flat sound. The 
tympanitic resonance due to solidification of lung, is much oftener 
marked in cases in which the upper lobes are affected, on the anterior 
surface of the chest, and especially over the middle third. Excepting 
cases in which, on the left side, a gastric sound is transmitted, it is 
rare that on the posterior surface more than an obscure or feeble 
non-vesicular resonance is discoverable. 

In cases in which an entire lung is solidified, I have observed a 
tympanitic resonance in different parts, varying not only in intensity, 
but in pitch. Thus in a case in which the right lung was solidified, 
the percussion-sound at the summit was dull, but distinctly tympa- 
nitic and high in pitch. Over the middle third the pitch was con- 
siderably lower, but the tympanitic resonance more intense. In the 
axillary region the tympanitic quality was also marked, and the pitch 
still lower than over the middle anterior third. 

In some instances the tympanitic resonance persists from day to 
day, during the course of the disease, gradually diminishing, receiving 
by degrees the vesicular quality of sound, becoming vesiculo-tympa- 
nitic, and finally assuming the normal character. But in other in- 
stances marked variations are observed at the examinations repeated 



ACUTE LOBAR PNEUMONITIS. 407 

on successive days : on one day the sound may be dull, amounting 
almost to absolute flatness, and on the next day it may become highly 
tympanitic. I have observed the change from a marked degree of 
tympanitic sonorousness to great dulness, to occur within the space 
of an hour. Without designing to discuss the subject of the rationale 
of the phenomenon under consideration, I will simply remark that 
these fluctuations, except when the sound is of gastric or intestinal 
origin, point to the bronchial tubes as the source of the tympanitic 
resonance in cases of solidification. The varying condition of the 
tubes as respects the accumulation of mucus or other morbid products, 
will perhaps account for the existence of sonorousness at one time, 
and dulness amounting nearly to flatness at another time. The 
situation in which the tympanitic resonance is apt to be most marked, 
viz., over the larger tubes, favors the same explanation. 

In cases of pneumonitis afi'ecting the lower lobe, the percussion- 
resonance over the unafiected lobe on the same side is frequently, if 
not generally, modified. The sonorousness is greater than in corre- 
sponding situations on the opposite side ; it is higher in pitch, and is 
vesiculo-tympanitic in quality. These characters are more marked 
on the anterior surface of the chest, but they may also be apparent 
posteriorly in the upper scapular region. On the side free from dis- 
ease the resonance is usually strongly marked, and highly vesicular. 

By means of percussion the limits of the inflammation may gene- 
rally be defined without difficulty. The change from the vesicular or 
a vesiculo-tympanitic resonance, to dulness or a non-vesicular sono- 
rousness, is generally abrupt, and the line of demarcation between the 
healthy and solidified lung is easily traced on the chest. In view of 
the fact that lobar pneumonitis extends over an entire lobe, and in 
the majority of cases is limited to a single lobe, the line bounding the 
limits of the afi*ected portion of the lung will, as a rule, be found to 
pursue a direction coincident with that of the interlobar fissure. 
Thus if the lower lobe be afi"ected, the line intersecting the several 
points at which the change in the percussion-sound is observed, ex- 
tends obliquely upward and outward, from between the fifth and sixth 
ribs, in a direction toward the vertebral extremity of the spinous ridge 
of the scapula, — this being the situation of the fissure separating the 
upper and lower lobes on the left side, and the middle and lower 
lobes on the right side. On the right side, in cases in which the 
inflammation extends to the middle lobe, the line pursues a direction 
upward and outward from the fourth cartilage. This is a point not 



408 DISEASES OF THE P.ESPIEATOET OEGAXS. 

only of interest, but one "wliicli may be in some instances of impor- 
tance in diagnosis. In the absence of tlie auscultatory phenomena 
distinctive of solidification of Inng, which, although generally present, 
may yet be absent, the question will perhaps arise whether marked 
dulness or flatness on percussion be not due to liquid efiiision ; in 
other words, the differential diagnosis between pneumonitis and 
pleuritis is to be made. Xow, if under these circumstances, the line 
denoting the limits of the dulness or flatness be found to occupy the 
situation of the interlobar fissure, while the body of the patient is in 
a vertical position, the question may be considered almost or quite 
settled. 

With the resolution of the inflammation, in proportion as the solid 
exudation disappears, the vesicular resonance, as already stated, re- 
turns. This is gradual, though frequently much progress is made 
within a short space of time. The dulness is sometimes observed to 
lessen materially in twenty-four hours. It is, however, a long time 
before complete equality in the resonance of the two sides is restored ; 
a marked disparity may exist for months after the patient has appa- 
rently recovered perfect health ; and it is probable that in some in- 
stances the symmetry of the two sides as respects percussion-reso- 
nance is never fully regained. 

Auscultation, in most cases of pneumonitis, furnishes numerous and 
important signs. As the inflammation does not invade simultaneously 
the whole of a lobe, but, commencing at one or more points, ad- 
vances thence in all directions, a certain period may elapse before any 
positive auscultatory phenomena are discoverable. This -will be the 
case especially if the poiuts of departure of the inflammation be cen- 
trally situated. The healthy parenchyma surrounding the portion 
inflamed, presents the phenomena originating in the latter from 
reaching the ear. Under these circumstances, according to Foumet, 
the existence of pneumonitis, taking into account the symptoms, maj 
sometimes be predicated on an exaggerated respiratory murmur over 
a portion of the chest. He states that the vesicles surrounding an 
inflamed portion of a lobe take on a supplementary activity, and give 
rise to an abnormally loud respiration. It is stated also by Stakes, 
that the first effect of inflammation prior to the production of the 
crepitant rale, is an exaggerated murmur. On the other band, 
Grisolle states that the effect of inflammation upon the adjoining lung- 
substance is oftener to diminish its activity, giving rise to an abnor- 
mally weak respiration. Both these statements, although they may 



ACUTE LOBAR PNEUMONITIS. 409 

at first appear to be contradictory, are correct ; in other words, the 
respiratory sound in the immediate vicinity of an inflamed portion 
may be either exaggerated or weakened. The opportunity of ob- 
serving one or the other of these effects, is occasionally presented in 
cases in which the existence of central pneumonitis is indicated by 
characteristic symptoms prior to the development of distinctive signs, 
which shortly make their appearance, showing that the inflammation 
has extended from its central situation to the surface. The oppor- 
tunity is also presented in cases in which the inflammation passes 
from one lobe to another, gradually invading the latter. I have noted, 
under these circumstances, in different cases, both exaggerated and 
weakened respiration ; and in the same case I have observed on two 
successive days, in the same situation, first exaggerated, and next 
weakened respiration. In some instances, while the area of the in- 
flamed lung is limited, especially if it be situated near the surface, a 
broncho-vesicular respiration precedes the appearance of other signs. 
The earliest and most characteristic of the positive signs of pneu- 
monitis in most instances, is the crepitant rale. This sign is incident 
to physical conditions belonging to the primary local effects of in- 
flammation, and is heard when the inflamed portion is sufiiciently 
large, and near enough to the surface for the sound to be transmitted. 
Contrary to the opinion of Skoda, it is present in a very large ma- 
jority of the cases of pneumonitis. Out of forty-four cases taken in 
regular order with a view to an analysis of the recorded physical signs, 
in thirty-two a crepitant rale was observed, and in twelve its presence 
was not noted. But of these twelve cases, in eight a single examination 
only was made, and in all at a period more or less remote from the 
commencement of the disease. It is probable that examinations re- 
peated, and made at an earlier period, would not have been negative 
as regards this sign in the greater proportion of the few instances in 
which it was not discovered. Of 149 examinations, in forty-five cases, 
made at different periods in the progress of the disease, the presence of 
the rale is noted in eighty-five, and its absence in sixty-four. The collec- 
tion of cases analyzed did not embrace cases of lobar pneumonitis 
occurring in infancy. My observations lead me to concur with others 
in the opinion that the crepitant rale is much less constantly present 
in children than in adults. It is perhaps oftener absent than present 
in infant life. The constancy of the rale in acute primitive pneu- 
monia, affecting the adult, is shown by the much more extensive re- 
searches of Grisolle. This author, in his treatise on pneumonia, based 



410 DISEASES OF THE RESPIEATORY ORGANS. 

on an analysis of 373 cases, states that he has only met with four in- 
stances in which this sign was not discovered at some period during the 
course of the disease. Different cases, however, present great dif- 
ferences as respects its abundance, loudness, proximity or remoteness, 
diffusion and continuance. The period when it is usually most 
abundant and loudest is early in the disease, prior to the time when 
the physical evidences of solidification, more or less complete, are 
present ; that is to say, during the first stage. During this stage, in 
some instances it exists in a marked degree, occupying the whole or 
the greater part of the inspiratory act, in other instances being com- 
paratively faint, and heard only at the end of inspiration. In some 
instances, even during this stage, it is not discovered in ordinary re- 
spirations, but is developed by forced breathing, and especially by 
the deep inspirations which precede and follow an act of coughing. 
In a small proportion of cases the methods just named fail to produce 
it, and the diagnosis must be based on other signs. It may be de- 
tected in the majority of cases, for a greater or less period, after the 
disease has advanced to the second stage. It is then, generally, con- 
fined to the end of the inspiratory act, and much more frequently re- 
quires for its production that the force of the act be voluntarily 
increased. In both stages it may be heard at different situations over 
the affected lobe or lobes, or it may be confined to a few points. It is 
much more apt to be diffused in the first stage, this, in fact, being 
very rarely the case in the second stage. Sometimes it seems to arise 
in close proximity to the ear, and at other times it apparently origi- 
nates at a distance. It may be appreciable during the whole career of 
the disease, even into convalescence, or it may cease at a period more 
or less removed from this epoch. 

Laennec described the crepitant rale as generally disappearing in 
the progress of the disease, and afterward returning during the 
period of resolution. This must be ranked among the instances (singu- 
larly few in number), in which the observations of the founder of 
auscultation were biassed by speculative notions. Moreover, the dis- 
tinctive traits of the true crepitant rale were not fully known by 
Laennec, and, hence, it was confounded by him with the sub-crepi- 
tant. The observer who seeks by daily explorations during the 
career of pneumonitis to verify the crepitant rale redux, will very 
often meet with disappointment. The crepitant rale, as just stated, 
may continue through the whole course of the disease. It may dis- 
appear and reappear at irregular intervals. I have known it to be- 



ACUTE LOBAR PNEUMONITIS. 411 

come more marked after the lapse of several days than at an early 
period in the disease. I have even observed it to become developed 
as late as the 17th day, when it had not been previously discovered ; 
but the regular occurrence of a returning crepitant rale, as a harbin- 
ger of recovery, cannot with propriety be said to constitute a portion 
of the natural history of pneumonitis. As a rule, when the rale, after 
continuing for a greater or less number of days, disappears, it is not 
reproduced, except as the sign of a new focus of inflammation. 

The sub-crepitant rale — a bronchial, not a vesicular rale, convey- 
ing the idea of small but unequal bubbles, wanting the equality, the 
dryness, and the extreme fineness of the true crepitant, and not 
limited to the inspiratory act, — may occur at any period of the disease. 
Present on both sides of the chest, in the early stage, and diffused 
especially over the posterior base, it denotes the coexistence of capillary 
bronchitis. The two rales may be combined and distinguished from 
each other, the crepitant appearing at the end of the inspiration, and 
the sub-crepitant in both acts. This I have observed in a case to which 
reference was made in treating of the crepitant rale in Part I. Ex- 
clusive of the very rare instances in which pneumonitis and capillary 
bronchitis are associated, the sub-crepitant rale is much more likely 
to occur at a late period in the disease, during the progress of reso- 
lution. Developed under these circumstances it is, in fact, the re- 
turning crepitant rale of Laennec. But its appearance is by no 
means constant. Indeed it is wanting in a large proportion of cases. 
The other bronchial rales, both moist and dry, are all liable to 
occur in cases of pneumonitis. Since, however, as a general remark, 
they imply the coexistence of bronchitis, which, save in a limited ex- 
tent, is only an occasional complication, the occurrence of the sibi- 
lant, sonorous, and mucous rales, as prominent physical phenomena, 
being limited to a small proportion of cases only, is in accordance 
with the pathological laws of the disease. Clinical observations show 
that these rales are far from being common in cases of pneumonitis. 
In the majority of cases, examinations, repeated at different periods, 
do not show their existence, except occasionally, as transient phe- 
nomena. It is rare for them to be prominent in cases in which the 
disease does not advance beyond the second stage. In the third stage, 
the moist or bubbling rales are much more likely to occur than in the 
two preceding stages. 

The infrequency of the occurrence of the bronchial rales, irrespec- 
tive of the sub-crepitant, in ordinary cases of pneumonitis, is shown 



412 DISEASES or THE RESPIRATORY OROAXS. 

by the following : of 148 examinations at difierent periods in forty-five 
cases, a sibilant rale is noted in seven, a sonorous in six, and a mucous 
in three instances. 

A friction-sound is sometimes discovered in auscultating over an 
inflamed lobe, but the proportion of instances in which this sign occurs 
in pneumonitis is extremely small. In forty-five cases, out of 149 ex- 
aminations it is noted in five examinations, made in three cases. 

In addition to adventitious sounds, the vast majority of cases of 
]3neumonitis are characterized by important modifications of the re- 
spiratory phenomena. The modifications constituting the bronchial 
and the broncho-vesicular respiration, very rarely fail in being deve- 
loped dm'ing the com*se of the disease. The bronchial respiration is 
absent in but an exceedingly small proportion of instances. Of the 
forty-five cases which I have selected for analysis, commencing with the 
last case recorded, and rejecting none till this number was completed, 
in five either the examinations were begun too late in the disease, or 
the records are imperfect with respect to this point. Excluding these 
five cases, out of the remaining forty the bronchial respiration was 
more or less marked in thuty-seven. In two the modification did 
not exceed that constituting the broncho-vesicular respiration ; and 
in the other exceptional case the patient died on the second day in 
the stage of engorgement, the disease being complicated with dilata- 
tion of the heart. In the large collection of cases analyzed by 
GrisoUe (373), the bronchial respiration was observed to cease two 
days before death in one, and was not developed in another of two 
cases in which the inflammation extended over an entire lung ; and 
of the cases in which the inflammation was limited to a single lobe, 
it was wanting in nine.^ The bronchial respu*ation is a sign of soli- 
dification. In connection with percussion it afi"ords e^ddence of the 
progress of the disease to the second stage. It denotes the continu- 
ance of the solidified state of the lung, indicating by its gradual dis- 
appearance the removal of the solid exudation. Other things being 
equal, its intensity is probably in proportion to the completeness of 
the solidification. As regards its development, it occurs much earlier 
in some cases than in others. I have known it to take the place of 
the vesicular mm-mm- in the space of twenty-four hom's. It may not 
appear till the second or third day after the date of the attack, or 
even still later. In a very large proportion of hospital cases it is 
found when patients first come imder observation. K we have an 

1 Op. cit. 



ACUTE LOBAR P2n^ E UM NITIS. 413 

opportunity of watching its development, we may observe that the 
transition fronj the vesicular murmnr is not abrupt, but takes place 
gradually, the broncho-vesicular modification preceding a well-marked 
bronchial respiration ; that is to say, the inspiratory sound loses the 
vesicular quality by degrees, until at length it becomes entirely tubu- 
lar or blowing. In som.e instances the presence of the crepitant rale 
prevents us from appreciating a well-marked alteration affecting the 
inspiration, until the sound becomes distinctly bronchial, the rale 
then either ceasing, or being heard only at the end of the act. In 
the progress of the disease the bronchial respiration attains its maxi- 
mum, as respects intensity and completeness ; continues without 
much diminution or alteration for a certain period, and gradually 
becomes less intense and complete, at length merging into the bron- 
cho-vesicular respiration. 

The bronchial respiration in acute lobar pneumonitis, is not a 
variable or fluctuating sign. As a rule, after it is developed, it may 
be discovered at each successive examination, until, in the progress 
of the disease, it declines and disappears. There are, however, occa- 
sional exceptions to this rule. I have known it to be absent and 
shortly reappear, its temporary cessation being perhaps due to casual 
obstruction of the tubes. Such obstruction during the period of the 
disease when the bronchial respiration may be expected to be present, 
rarely occurs in ordinary cases of pneumonitis. During the progress 
of the disease in 40 cases, the bronchial respiration existed in 107 
out of 146 examinations made on different days. Of the remaining 
39 cases, in 7 there was absence of respiratory sound, and in 32 the 
modification came under the denomination of broncho-vesicular. 
These enumerations show the persistency of this sign in cases of 
pneumonitis. 

The intensity of the bronchial respiration and certain of its cha- 
racters, vary in different cases. Generally cases of pneumonitis 
present, for a greater or less period, all the elements which this 
physical sign in its completeness embraces, viz., a tubular, shortened, 
high-pitched (occasionally metallic) inspiration, followed, after an 
interval, by an expiration, prolonged, more intense, and higher in 
pitch (oftener metallic) than the sound of inspiration. Of 27 cases, 
in the records of which the bronchial respiration is described as re- 
spects the presence or absence of these several elements, in 24 they 
were all present for a period greater or less. In two cases a tubular 
inspiration existed without any sound of expiration, and in one case 



414 DISEASES OF THE EESPIRATORY ORaANS. 

an expiratory sound existed alone. Enumerating the successive 
examinations made on different days in these 27 cases, and the result 
is as follows : Out of 86 examinations, in 6b all the elements of the 
bronchial respiration were present. Of the remaining 21 examina- 
tions a tubular inspiratory sound, without a sound of expiration, 
existed in 11, and an expiratory, without an inspiratory sound, in 10. 
In six of the latter 10 instances, however, the inspiratory sound was 
drowned by the crepitant rale. 

It was stated by Jackson, and it is repeated by Grisolle, that in 
the development of the bronchial respiration the abnormal modifica- 
tion is first manifested by a prolonged expiration. The earliest 
change is, to say the least, generally more obvious in expiration 
than in inspiration. The former frequently is not only prolonged, 
but becomes intense and high in pitch, while the latter is compara- 
tively feeble, and still retains more or less of the vesicular quality — 
in other words, is broncho-vesicular. It is rarely, however, if ever, 
the case, that in connection with a prolonged, intense, high-pitched 
expiration, the inspiratory sound is not at the same time more or less 
altered, being less vesicular and higher in pitch than on the opposite 
side of the chest, and also shortened or unfinished. On the other 
hand, at a later period, when the bronchial is about to merge into 
the vesiculo-bronchial respiration, the change is frequently, if not 
generally, first manifested in the inspiration, vfhich becomes weaker 
and assumes more and more the vesicular quality, while the expira- 
tion remains prolonged, high-pitched, and relatively more intense. 
At a still later period the expiratory sound may disappear, leaving 
the inspiration still less vesicular and higher in pitch than the normal 
murmur. 

The transition from an intense bronchial to a broncho-vesicular 
respiration, like that of the percussion-sound from marked to mode- 
rate or slight dulness, is gradual ; yet in the one, as in the other 
case," frequently a considerable alteration is often observed to take 
place within a short space of time. A striking diminution in inten- 
sity of the bronchial respiration, and the conversion of a purely 
tubular to a vesiculo-tubular inspiration, are sometimes observed by 
comparing the examinations of two successive days. A return to 
the normal vesicular murmur is rarely complete for some time after 
convalescence is established. Even when the patient is sufficiently 
restored to be out of doors, the respiration over the affected lobe, or 
lobes, often continues broncho-vesicular. When the characters of 



ACUTE LOBAR PNEUMONITIS. 415 

the broncMal and the broncho-vesicular respiration have nearly or quite 
disappeared, the respiratory sound over the affected lung is often 
abnormally feeble, being sometimes scarcely appreciable except the 
breathing be forced. Fournet states that the bronchial respiration 
is apt to be succeeded in the affected portion of lung by an exag- 
gerated vesicular murmur. Judging from the cases that I have ob- 
served, I should say that the rule is directly the reverse. With re- 
spect to this point, the following are the observations of Grisolle : — 
Of 103 convalescents discharged from hospital, between the twentieth 
and fifty-fifth days of the disease, 37 had no morbid signs ; in 36 the 
respiration was weak ; in 14 the respiration was slightly blowing ; 
and in 16 there existed sub-crepitant or other bronchial rales."" 

In the majority of cases of pneumonitis the disease being limited 
to the lower lobe of one lung, the abnormal modifications of the respi- 
ratory sounds, as well as other physical phenomena, are to be sought 
for especially on the posterior surface of the chest below the spinous 
ridge of the scapula. They are also manifested on the lateral surface 
below a diagonal line corresponding to the interlobar fissure. Ante- 
riorly the bronchial respiration, and also the crepitant rale, may be 
discovered at the base of the chest, but it not infrequently happens 
that over the small portion of the lower lobe which extends in front, 
auscultation fails to detect any morbid phenomena. Posteriorly and 
laterally, if the stethoscope be employed by passing the instrument 
over successive portions of the chest from above downy>^ard, the change 
from the vesicular murmur to the bronchial respiration is found to be 
abrupt, not gradual. If the line indicating the situation of the inter- 
lobar fissure have been already traced by the change in the percus- 
sion-sound, the transition from the vesicular murmur to the bronchial 
respiration will be found to take place on the same line. The limits 
of solidification may thus be defined by auscultation as well as by 
percussion, and it is in some cases easier to trace the boundaries by 
means of the former than by the latter method. On the back, the 
characters of the bronchial respiration are shown in striking contrast 
by auscultating alternately above and below the spinous ridge of the 
scapula. 

If the whole lung become affected, the different lobes being attacked 
in succession, the bronchial respiration will present differences as 
respects intensity, and other characters, in different situations. On 
the right side in front, I have observed a striking disparity in 

» Walshe, op. cit. 



416 DISEASES OF THE EESPIEATOllT OKGAXS. 

pitcli and other points over tlie upper, middle, and loTver lobes, the 
pitcli and intensity diminisMng from above down-ward in these three 
situations. The same disparity I have also observed over different 
points within the boundaries of the same lobe. In accordance with 
the fact that when an entire lung is affected, even if the upper lobe 
be invaded secondarily, resolution takes place first in this lobe, the 
bronchial respiration will be found to continue longer posteriorly 
below the spinous ridge of the scapula, than over the upper and 
middle thirds in front. It will be found frequently, if not generally, 
to continue longer in the lower scapular, than in the infra-scapular 
region; but this is probably owing to the proximity in the former 
region to the larger bronchial tubes. 

Over the unaffected side in cases of pneumonitis the respiratory 
murmur is frequently intense, and the vesicular quality highly marked, 
in short, exaggerated. If the affection be limited to a lobe, accord- 
ing to Foumet, the respiratory sound over the unaffected lobe is even 
more exaggerated than on the opposite side on the chest. So far as 
my experience goes, the reverse of this is nearer the truth. The 
murmur over the upper lobe on the affected side is sometimes ex- 
tremely feeble, almost null, so that conjoined with a tympanitic per- 
cussion-resonance, the physical evidences of emphysema are present.* 
I have, however, observed an exaggerated respiration in the upper 
lobe when the lower was solidified, the intensity being notably greater 
than over the upper lobe in the tmaffected side. 

Auscultation fornishes important vocal phenomena in pneumonitis. 
In the second stage, over the solidified lung, bronchophony occurs in 
a very large proportion of cases. Of '21 cases iu the histories of 
which is noted either the presence or absence of this sign, it was ob- 
served in 25, and not discovered in two. By broDchophony, it will 
be borne in miad, I do not mean simply exaggerated vocal resonance, 
but a greater or less apparent approach of the voice to the ear of 
the auscultator. In the great majority of instances this increased 
proxLooitv of the voice is accompanied by an abnormal resonance or 
reverberation, but not invariably. It is not very infrequently the 
case that the approach of the voice and the reverberation do not corre- 
spond, as respects relative intensity. The voice sometimes seems 
very near the ear when the resonance is but little exaggerated ; and, 

^ In Fart I. 1 iiave £:agge;ted ihe inq-aiiy whether an emphrseiratons condition mar 
not serve to aecoimt for the Teacnlo-tyn^panitie Tesonance "which so frequemly exists 
over the tapper lobe when the lo'wer is solidified. 



ACUTE LOBAE PNEUMONITIS. 417 

on the other hand, the resonance may be intense while the voice re- 
mains as distant as in the normal condition. An increased vibration 
or thrill is frequently felt by the ear applied either directly to the 
chest, or to the stethoscope. The latter may or may not accompany 
the bronchophony and vocal resonance, and it is sometimes present 
when the other vocal phenomena are wanting. In intensity there is 
not a uniform correspondence between it and the vocal transmission 
and resonance, more than exists between the two latter. The vibration 
or thrill, indeed, may be greater on the unaiFected side of the chest 
in pneumonitis, when bronchophony and increased reverberation are 
marked over the solidified lung. The bronchophony in difi'erent cases 
of pneumonitis is variable in degree. The vocal sound appears in 
some instances to emanate directly beneath the ear or stethoscope, 
and between this maximum and a slight approximation appreciable 
only by a careful comparison of the two sides of the chest, every 
grade of intensity may be observed in different cases, and sometimes 
in a series of successive examinations in the same case. When the 
bronchophony has a marked intensity, or, in other words, is strong, 
the vocal sound in some instances appears to strike the ear with a 
certain force, giving rise to a sense of concussion or shock, like that 
felt when auscultation of the voice is practised over the trachea. The 
pitch of the vocal sound in some instances is notably high, exceeding 
that of the tracheal voice. It acquires sometimes a metallic tone. 
Other things being equal, the maximum of the degree of intensity to 
which either bronchophony or exaggerated vocal resonance attains, 
in the progress of pneumonitis, denotes the greatest amount of solidi- 
fication. It coexists, therefore, with the greatest loss of vesicular 
resonance on percussion, and with the maximum of intensity of the 
bronchial respiration. As the disease pursues its course, these vocal 
phenomena reach their maximum by degrees, and gradually become 
weaker as the solidification decreases in the progress of resolution. 
In this retrograde course, when bronchophony and exaggerated reso- 
nance are associated, the former disappears first, the latter continu- 
ing to be more or less marked for a period varying considerably in 
different cases. With respect to the vocal, as well as the respiratory 
phenomena indicative of solidification, often a marked diminution is 
observed to occur within a short space of time, and occasionally they 
disappear rather abruptly. 

The duration of the vocal signs in different cases of pneumonitis is 
variable. Of 88 examinations, made on different days in 27 cases, 

27 



418 DISEASES or THE P.ESPIEATOEY 0RGA^'5. 

bronchophonY existed in 61 and was absent in 27. The examinations 
in wbich it was absent were mostly made during the latter part of the 
disease, the sign having existed, but disappeared. When, howeyer, it 
is once developed, it is a persistent sign until it disappears as the 
consequence of the progress in resolution ; that is, it is generally 
found at each successive examination. This statement is in opposi- 
tion to the opinion of Skoda, who maintains that the bronchophonic 
voice is constantly fluctuating, sometimes even appearing and disap- 
pearing in the conrse of a few moments. An analysis of a series of 
recorded examinations shows this opinion to be incorrect. Of the 88 
examinations in 27 cases just referred to. in but two instances was 
the sign absent when its existence was noted at the examination pre- 
ceding, and also that succeeding the one on which it was found to be 
wanting. 

Bronchophony in the same case, at the same moment, is by no 
means equal at different points over the affected lobe or lobes. Its 
highest intensity is in cases in which the upper lobe is affected, over 
the portion of the summit of the chest in front, situated nearest to 
the largest bronchial divisions. Posteriorly, when the lower lobe is 
affected, it is generally more marked over the lower scapular, than in 
the infra-scapular region. Well-marked bronchophony may exist 
over the larger bronchial tubes, while at a little distance the vocal 
resonance is simply exaggerated. It is not uncommon to find bron- 
chophony over the scapula, and exaggerated resonance below the 
scapula. 

By means of an abrupt change in the vocal phenomena, limiting by 
the use of the stethoscope the space from which the sounds are re- 
ceived, the interlobar fissure, in cases of pneumonitis affecting a single 
lobe, may be often traced on the chest as well as by the percussion 
and the respii'atory sounds, in the manner already described ; and 
when this has been done by means of the two latter phenomena, the 
auscultation of the voice fui-nishes another method of verification. 

The transmission of the articulated voice or speech, in other words 
pectoriloquy, is a physical sign occasionally observed in cases of 
solidification from pneumonic inflammation. In 2 of 27 cases words 
(numerals) spoken aloud were transmitted. In 2 other cases whis- 
pering pectoriloquy was complete, and in several instances whispered 
words were imperfectly transmitted. Contrary to the opinion of 
Walshe, who regards whispering pectoriloquy as eminently distinctive 
of a cavity, I have found it oftener present in connection with soli'iifi- 
cation than the transmission of words spoken aloud. 



ACUTE LOBAR PNEUMONITIS. 419 

When -whispered words are not transmitted, a souffle, or puff is 
generally produced over solidified lung, which claims the attention of 
the auscultator. Under certain circumstances in pneumonitis, and 
other affections involving solidification, e. g. tubercle, it constitutes a 
valuable physical sign, its significance being the same as broncho- 
phony and the bronchial respiration. It is valuable, not only as con- 
firmatory of the fact of solidification, associated with the signs just 
named, but still more because it may be developed in some instances 
in which they are wanting. The souffle or puff, accompanying the 
act of whispering, and heard over solidified lung, is more intense than 
that over healthy lung in corresponding situations on the opposite 
side of the chest, and acute or higher in pitch. The contrast is as 
striking as between a vesicular and a well-marked bronchial respira- 
tory sound. In some cases it is distinctly marked over a portion of 
lung solidified, and no sound is developed over a corresponding situa- 
tion on the healthy side. Owing to the small number of instances in 
which the bronchial respiration and bronchophony are absent in ordi- 
nary pneumonitis, this vocal sign is of less diagnostic importance than 
in other affections in which other phenomena denoting abnormal 
density of lung are less commonly present. 

In some cases of pneumonitis, it is stated, the voice in passing 
through the chest acquires the segophonic characters, viz., tremulous- 
ness and acuteness of pitch. Some observers, indeed, profess to have 
discovered strongly marked segophony in pneumonitis; and it is 
claimed that this vocal sign may occur in cases in which there is no 
pleuritic effusion. The latter point it is difficult to establish, since, if 
in fatal cases, no liquid is found, it may have existed during life and 
been absorbed. I have never met with a well-marked bleatino; into- 
nation of the voice in pneumonitis ; but the elevation of pitch has in 
several instances attracted my attention. 

Inspection of the chest discloses, in a certain proportion of cases 
of pneumonitis, abnormal appearances deserving attention. Coinci- 
dent with the attack, the movements of the affected side may be 
visibly restrained, attributable, at this stage, to the pleuritic pain 
which is generally present in the early part of the disease. At a 
later period, during the second stage, if a single lobe be affected, a 
disparity in expansion-movement at the inferior portion of the chest 
is sometimes obvious, and in other instances not apparent. If the 
entire lung become affected, a disparity is frequently well marked. 
It is more marked if the breathing be labored, or voluntarily forced. 



420 DISEASES OP THE RESPIRATORY ORGAN-S. 

Under these circumstances the three types of breathing may be con- 
spicuous on the unaffected side, while they are but feebly manifested 
on the side diseased. The deficient expansion of the affected side 
when pain has ceased to be a prominent symptom, in other words in 
the second stage, is attributable to the augmented size of the lung, 
and the loss of its contractility. The side, in fact, is in a measure 
dilated permanently, and the incompressibility of the solidified lung 
prevents its contraction to the same extent as in health. The disparity 
under these circumstances is increased by the healthy side taking on 
a supplementary activity. 

This statement is in opposition to the opinion of Grisolle, who, 
exclusive of instances in which the movements are restrained by 
excessive pain, does not admit a disparity between the two sides in 
this respect. 

The intercostal depressions are not lost, except in certain cases 
characterized by the presence of liquid effusion. 

After the stage of resolution, more or less contraction of the chest 
may be evident on inspection. It has been doubted by high autho- 
rity^ whether this ever occurs except as the sequel of pleuritic effusion 
which coexisted with pneumonic solidification. On this point my own 
observations lead me to accord with the opinion of Stokes and Walshe, 
which refers the contraction succeeding pneumonitis in certain cases, 
to the diminished bulk of the affected portion of the lung in conse- 
quence of the removal of the solidifying deposit, and the contraction 
of the plastic exudation on the surface. 

With regard to mensuration, my recorded observations do not fur- 
nish sufficient data to serve as the basis of any conclusions. Walshe 
states that in a'minority of cases he has found positive, though slight, 
increase of size at the base of the chest on the affected side in the 
second stage of the disease. The occurrence of contraction of the 
affected side after recovery is indubitable. The only question relates 
to the pre-existence of liquid effusion in all such cases. On this 
question an opinion has just been expressed. 

Finally, palpation furnishes physical phenomena in different cases 
of pneumonitis, somewhat contradictory. As a rule, the vocal fre- 
mitus is increased, in the second stage of the disease, over the solidi- 
fied lung. But the exceptions to this rule are not very infrequent. 
In some of the exceptional instances no disparity as respects this 
sign is appreciable on comparing the two sides of the chest. In 

' Woillez, Grisolle. 



ACUTE LOBAR PNEUMONITIS. 421 

other instances the fremitus is greater on the unaffected side. If the 
left lung be the seat of the disease, the explanation may be that the 
fremitus over the solidified lung is not increased, as naturally it is 
frequently more marked on the right than on the left side. But I 
have observed the fremitus to be greater on the left side, ^^hen the 
pneumonitis was seated on the right lung. This shows that an effect 
of solidification, under certain circumstances, is a diminution of the 
natural fremitus. Instances of this description are, however, it is 
probable, extremely rare. 

Diagnosis. — The space which has been devoted to the considera- 
tion of the physical signs belonging to pneumonitis may lead the 
reader not practically conversant with the subject, to suppose that 
the diagnosis involves greater difficulties than actually exist. The 
truth is, with a knowledge of the semeiological phenomena of the 
disease, and an acquaintance with the diagnostic features of other 
affections presenting some characters in common, it is recognized 
with promptness and positiveness in the great majority of cases. 

If a person be seized with a chill, which is followed by high febrile 
movement, and lancinating pain in the chest, referred to the neigh- 
borhood of the nipple ; accompanied by cough, with an adhesive, 
rusty expectoration, and a well-marked crepitant rale is found on 
auscultating the posterior surface of the chest on one side, it is at 
once evident that he is attacked with pneumonitis seated in an infe- 
rior lobe. This group of diagnostic phenomena is presented in a 
pretty large share of the cases of simple acute pneumonitis at the 
time when they first come under the observation of the medical prac- 
titioner. Of these phenomena the characteristic expectoration and 
the physical sign may be said to be pathognomonic. A viscid expec- 
toration, containing a variable quantity of blood in intimate combina- 
tion, is a symptom belonging exclusively to inflammation of the pul- 
monary parenchyma. If this statement be not correct in the most 
rigorous sense, it may at all events be practically so regarded.^ So 
with regard to the crepitant rale, if we are sure of its presence, that 

' According to the observations of Dr. Remak, of Berlin, if the sputa from a patient 
affected with pneumonitis, after having been macerated for some time in vv^ater. be 
placed on dark-colored glass, and carefully examined, minute fibrinous concretions may 
be discovered, v^^hich are probably casts moulded in the minute bronchial ramifications. 
Dr. Remak succeeded in discovering fibrinous casts in 50 successive cases, between the 
third and seventh days of the disease. Other observers have not met with equal success. 
Vide Art. by Dr. Da Costa, Am. Jour, of Med. Sciences, Oct. 1855. 



4^ 



D'TSSASSS OF litit EiLiPlS. 



iSy rf tEifi efiai-stcters whieB: (iisfeiBgwA h :"_ 
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-t1 ±r =iorTi5 of 



ACUTE LOBAR PNEUMONITIS. 423 

Pneumonitis, as lias been seen, in general runs rapidly into the 
second stage. In tHs stage new diagnostic features are added. The 
rusty expectoration and crepitant rale continue, but frequently be- 
come less marked. The added symptoms and signs pertain chiefly 
to the solidified condition of the lung. The function of h^ematosis 
being compromised in a greater degree, the respirations are accele- 
rated, cceteris paribus, in proportion to the completeness of the solidi- 
fication and the extent of the pulmonary organs involved. The alse 
nasi dilate, and there may be lividity of the prolabia and face. The 
cheeks often present a circumscribed flush. The acceleration of the 
breathing is out of proportion to the frequency of the pulse. The 
physical evidences of solidification are easily ascertained. On per- 
cussion, the chest over the inflamed lobe is found to be notably dull, 
with a marked increase of the sense of resistance and diminished 
elasticity. In the majority of cases, as has been repeated more than 
once, a single lobe only is inflamed, and this is the lower lobe. It is 
important for the student to recollect the relations of the inferior lobe 
to the anterior and posterior surfaces of the chest. So small a portion 
extends in front, that in many, if not most instances, physical exami- 
nation anteriorly is comparatively unimportant. The signs emanating 
from the afiected lobe are to be sought after behind, below the spinous 
ridge of the scapula. The interlobar fissure crosses the lateral sur- 
face of the chest obliquely, and its situation is generally determinable 
by the abrupt change in the percussion-sound. The fact of a line 
indicating the limits of dulness on the lateral surface of the chest, 
corresponding in direction with the interlobar fissure and not varying 
with the position of the patient, is a diagnostic feature in itself almost 
conclusive. Assuming the inferior lobe to be the seat of solidifica- 
tion, in the lower scapular and infra-scapular regions, and laterally 
below the line of the interlobar fissure, more or less of the characters 
embraced in the bronchial respiration are present in the vast majority 
of cases. Bronchophony or exaggerated vocal resonance is present 
also, with few exceptions ; also the bronchial souffle or high-pitched 
puff with whispered words. In the larger proportion of instances, at 
least in adults, the evidence afforded by auscultation of the respira- 
tion and voice is corroborated by an increased vocal fremitus. If the 
upper lobe be primarily the seat of the inflammation, the physical phe- 
nomena will, of course, be manifested within its limits, viz., in front 
above the fourth rib, behind in the upper scapular region, and later- 
ally above the interlobar fissure. The occurrence of highly marked 



424 DISEASES OF THE RESPIRATORY ORGANS. 

tympanitic or tubular percussion-resonance over solidified lung, espe- 
cially anteriorly wlien the superior lobe is affected, is a point not to 
be forgotten. It is superfluous to add that if tbe inflammation ex- 
tend beyond tbe lobe primarily attacked, an event occurring at a 
period more or less remote from tbe date of tbe attack, the local 
phenomena will be reproduced over the lobe or lobes which are suc- 
cessively affected. 

Of the signs which enter into the physical diagnosis of pneumonitis 
advanced to the second stage, excepting the crepitant rale, none are 
peculiar to this disease. Dulness on percussion, the bronchial respi- 
ration, bronchophony, exaggerated vocal resonance, the acute vocal 
souffle, and increased fremitus, may all be found in connection with 
other affections involving pulmonary solidification. The situation and 
limitation of the portions of the chest in which the signs are observed, 
together with the antecedent and concomitant symptoms, suffice for 
the discrimination of the solidification which arises from lobar pneu- 
monitis. But the circumstances involved in the differential diagnosis 
will be noticed presently. 

The signs by which the progress of the disease from the first to the 
second stage is ascertained, have been already sufficiently considered. 
It remains to devote a few remarks to the diagnostic characters which 
belong to the third or purulent stage. The transition to this stage, 
in the rare instances in which it occurs, is not, like that of the first 
to the second stage, signalized by the development of a new series of 
striking physical phenomena. The signs of solidification continue ; 
and, in fact, there are no criteria by which the occurrence of the third 
stage may be in all instances positively ascertained. The existence 
of this stage may be inferred after a protracted duration of the dis- 
ease, when the evidences of resolution of the disease fail to occur, and 
the symptoms denote an unfavorable termination, not directly in con- 
sequence of the extent to which hsematosis is compromised (for death 
thus produced takes place in the second stage), but as the result of 
asthenia and apnoea combined. A symptom which has a positive 
bearing on this question, is an abundant puriform expectoration, 
sometimes taking place rapidly like the discharge from a ruptured 
abscess, and occasionally emitting a fetid odor. A physical sign 
possessing considerable significance is the occurrence of abundant 
moist bronchial rales, at a late period, not preceded by general bron- 
chitis coexisting with the pneumonitis, the dulness on percussion re- 
maining undiminished, the bronchial respiration and voice becoming 



ACUTE LOBAR PNEUMONITIS. 425 

less marked, these circumstances being taken in connection with 
symptoms denoting a fatal tendency, viz., prostration, frequency and 
feebleness of the pulse, delirium, etc. 

The formation of abscesses, and their evacuation into the bronchial 
tubes, leaving cavities, are among the occasional events incidental to 
the progress of this disease.^ Do excavations thus formed give rise 
to distinctive signs, viz., the cavernous respiration and voice, and 
tympanitic resonance on percussion, with, in some instances, the 
cracked-metal intonation ? My own observations do not supply facts 
bearing on this question. Judging from the physical conditions in- 
cident to the formation of cavities under these circumstances, and 
from the testimony of experienced observers, the physical signs occa- 
sionally indicating excavations otherwise formed, and which will be 
noticed more especially in connection with tuberculous disease, are to 
be deemed possible, but by no means of probable occurrence. On this 
point Skoda remarks as follows : " I have frequently examined patients 
suffering from pneumonia, in whose lungs newly formed abscesses were 
found after death ; but I have never, in any single instance, recog- 
nized the presence of abscess by the aid of auscultation or percussion. 
In every case, the abscess, though communicating with the bronchial 
tubes, was filled with pus or sanies."^ 

The progress of the resolution of pneumonitis is indicated by dimi- 
nution of the dulness together with the sense of resistance felt on 
percussion; decrease of the intensity of the bronchial respiration, 
which, becoming first broncho-vesicular, gradually assumes the normal 
characters ; cessation of bronchophony, and the return to the normal 
vocal resonance ; disappearance of an undue vocal fremitus, — these 
changes in the physical phenomena associated, of course, and gene- 
rally succeeding rather than anticipating a marked improvement in 
the cough, respiration, etc. Facts relating to this point have entered 
into the consideration of the physical signs furnished by the different 
methods of exploration in this disease. 

Pneumonitis, so far as symptoms are concerned, is sometimes re- 
markably latent. Expectoration, cough, pain, may all be wanting, 
and the respiration be but little increased in frequency. The dis- 
ease fails to present its usual symptomatic phenomena when it is con- 
secutive, much oftener than when primary ; as w^hen it is developed 

' Of 750 cases treated in the great Hospital of Vienna, from 1847 to 1850, pulmonary- 
abscess was observed in but a single instance. 
2 Op. cit. Am. edition, page 311. 



426 DISEASES OF THE EESPIRATORY ORGANS. 

in the course of fevers, purulent infection of the blood, etc. Under 
these circumstances the diagnosis is to be based almost exclusively on 
the physical signs. But as regards the latter, the disease may be to 
a greater or less extent latent ; in other "words, physical phenomena 
which are usually present in a marked degree, may be obscure or 
absent. Thus, not only is the crepitant rale sometimes wanting, but 
also the bronchial respiration, bronchophony and exaggerated vocal 
resonance, and fremitus. The solidification which occurs in the latter 
stage of fevers and other affections, and characterized by the absence of 
the usual granular deposit (hypostatic pneumonitis), is the form most 
apt to be deficient in the group of signs just named. Instances in 
which, together with these signs, all the distinctive symptoms are 
also wanting, must be exceedingly rare ; yet it is not impossible that 
such a case may be met with. The diagnosis would then rest mainly 
on the evidence of solidification extending over a lobe, which by means 
of percussion would still be available. Inasmuch, however, as lobar 
solidification may take place irrespective of inflammation (from 
oedema), the existence of pneumonitis notwithstanding this evidence 
might be Cjuestionable. Fortunately a clinical problem so intricate as 
that just supposed, although within the limits of possibility, is re- 
moved far beyond the boundaries of the probable. 

The different affections from which pneumonitis is practically to be 
discriminated, are acute ordinary bronchitis, capillary bronchitis, 
acute pleuritis, dilatation of the bronchia, acute phthisis, and pulmo- 
nary oedema. I will consider briefly the more important of the points 
involved in the differential diagnosis from these affections respectively. 

With a proper knowledge and application of physical exploration, 
pneumonitis need never be confounded with acute ordinary bron- 
chitis ; but guided exclusively by symptoms, the discrimination is not 
always easy, and in some cases it is impracticable. Moreover, the 
two affections may be conjoined, and under these circumstances the 
question whether the bronchitis be complicated with pneumonitis, or 
not, is to be settled mainly by the physical signs. Simple bronchitis 
and simple pneumonitis present a striking contrast in several promi- 
nent symptoms. The pain in pneumoi^tis is sharp, lancinating, and 
generally referred to the vicinity of the nipple. In bronchitis, if 
pain be present, it is dull, contusive, and situated beneath the ster- 
num. The expectoration in bronchitis rarely contains blood, and, 
when present, it is in the form of bloody points or streaks. In pneu- 
monitis bloody expectoration is common, and the blood is intimately 



/ ACUTE LOBAR PNEUMONITIS. 427 

mixed Tvith viscid mucus, giving rise to the characteristic rusty sputa. 
The febrile movement in cases of acute pneumonitis is generally in- 
tense, while in ordinary bronchitis, however acute, it is only moderate. 
More or less acceleration of the breathing generally characterizes 
cases of pneumonitis, and occurs only occasionally in ordinary bron- 
chitis. 

But the physical phenomena are more distinctive. The crepitant 
rale is wanting in bronchitis, nor in the ordinary form of that affec- 
tion is there any rale approximating to the crepitant sufficiently to 
occasion any liability to error. The sonorous, sibilant, and mucous 
rales may be present more or less combined, and these rales are rarely 
prominent in cases of pneumonitis, except it be associated with gene- 
ral bronchitis. When observed in cases of pneumonitis not associated 
with general bronchitis, they are limited to one side of the chest, save 
in the very rare instances of double pneumonitis ; but in bronchitis 
they are found on both sides. The chest in cases of bronchitis every- 
where preserves its normal sonorousness on percussion, which, in- 
deed, may be abnormally increased. In pneumonitis, on the other 
hand, soon after the access of the disease, marked dulness, with in- 
creased sense of resistance, is found to exist over a space correspond- 
ing in size and situation to one of the pulmonary lobes. Broncho- 
phony, exaggerated vocal resonance and fremitus, and the acute 
bronchial souffle, with whispered words, belong to the history of 
pneumonitis, and are never produced as effects of bronchitis. 

Between pneumonitis and capillary bronchitis there are more points 
of similitude ; nevertheless, the points of dissimilitude are amply suffi- 
cient for the differential diagnosis. Capillary bronchitis is accom- 
panied by greater embarrassment of respiration and suffering from 
defective hsematosis, than obtain in pneumonitis. The acceleration 
of the pulse is greater. The rusty sputa are wanting ; blood, if 
present, existing in streaks. Reliance, however, must be placed 
chiefly on the physical signs. The percussion-resonance in capillary 
bronchitis generally remains unaffected, and may be abnormally in- 
creased. If dulness occur, it arises from collapsed lobules, and is 
not found to extend over a space corresponding to an entire lobe. 
Auscultation discloses a sub-crepitant rale, succeeding or coexisting 
with the sibilant rale, and existing on both sides of the chest over 
the posterior surface. The existence of this rale on the two sides is 
a fact eminently distinctive, but aside from this fact, the intrinsic 
differences between the sub-crepitant and the true crepitant rales, 



428 DISEASES or the EESPISATOIRT OE&AIs-E- 

-which, liare been fnUy pointed out, suffice for their discrinnnatiDii ^ 
from eacli otter. TmaHy, in capillarj, as in ordinary acnte bron- 
cMtis, "broncMal respiration, "broncLoplionT, increased Tocal resonance, 
and the acute bronckial soKMe -vdth -wliispered vords, are vanting- 

Tiie diagnostic featnrei of acute pleurisy are to be cofi^isrei 
iiereafter. It suffices for tbe present object to state tbat tte more 
important of tbese featnres arise from tbe aeerannlation of a con- 
siderable qnantiiy of Bqnid effusion "within l3ie jflenral sac Tbe 
pbysical signs denoting tbe presence of fluid in tbe cbest, tc^edSiEr 
idtb tbe absence of the crepitant rale and the pbenomena denoflmg a. 
marked degree of pulmonary solidification, establish the differential 
diagnosis. Moreover, in pleurisy the febrile morement is less i^B^feaa^ft 
than in acute pneumonitis ; cougb and expectoration are frequHirfty 
sligbt or altogether absent ; the rusty sputa are wanting, and tbe 
matter of the expectoration, unless broncMtiB be associated, is unal- 
tered mucus. It is not Tery unc:r::r r. :^"t practitioners pc 
an imperfect tnoTrledge of tlie j:: , i and practice of 
exploratiouL to mistake pnenmonitis for pleurisy, and viae "Dsrma. 
Due acquaintance "with the circumstances inrolred in dist 
pulmonary solidification fi'om liquid effusion, mQ obviate the 
to tliis error. Tbe points of distinction between these two morlM 
conditions bare been already considered, and will be recajntulated in 
connection witb the subject of pleurisy. 

Dilatation of the bronchia, in connection with an attack of 
broncbitis, gives rise to certain of tbe • ': ^ ' : ^ "r: ■ ' : - -_ ■ im 
moniiis, viz., broncbial respiration and : : i ._ _ _ i ~ : 
Toeal resonance, togeliiea' with dolne^ an pereussioii. The symp- 
tams incident to the acute bifflfflidiiiaB, assodated with the physical 
phenomena pertaining to the biraiMJ^al «fflatation, if tiie practitiomsr 
be not aware of the previous existifmBe «ff this leaon, might Iteafl i» 
the suspicion of pneumonitis advanced to tiie stage of B^MfcaftamL 
An investigation of the hist cry si;d present phenomeTm,m sa^a 
case, will show tiiat chronic : : :.; _ md expectoration have edstei 
for a greater or less period prior to the attack ; and that the signs 
suggesting pneumonic solidification are not, as in lobar pneumonitis, 
either bounded by a line coincident with the interlobar fissure, or 
extending over the entire lung on one side. In tbr ,- -is of the 
case, after the symptoms of the acute bronchial iij^a.i_ii.i "i ' i '^^ 
relieved, percussion and auscultation show the physical t'i - 1 - -^ 
Btill persisting, owing to the permanency of the lesiDEE. I _ i : 



ACUTE LOBAK PNEUMONITIS. 429 

the bronchiae is an affection of such rare occurrence, that it falls to 
the lot of but few physicians to be called to discriminate between it 
and other affections. 

Cases of rapid and extensive tuberculosis may present a group of 
symptoms and signs, which, without due attention, may for a time 
deceive the practitioner. Dulness on percussion, the bronchial respi- 
ration, bronchophony or exaggerated vocal resonance, and fremitus, 
with the sub-crepitant, and possibly a crepitant rale, may coexist 
with accelerated breathing, frequent pulse, cough and expectoration, 
lancinating pains, these symptoms having been so rapidly developed 
as not to suggest at once the idea of tuberculosis. Careful and con- 
tinued investigation, however, will lead to the discovery of certain of 
the positive features of phthisis, and at the same time authorize the 
exclusion of pneumonitis by the absence of some of its distinctive 
traits. In the vast majority of cases of phthisis, the deposit occurs 
first near the apex of the lungs. The physical signs will, therefore, 
be found at the summit of the chest. Pneumonitis attacks the upper 
lobe primarily in but a small proportion of cases, and hence, the 
situation of the physical phenomena in itself should excite suspicion 
of tubercle. A tuberculous deposit rarely extends within a brief 
period over an entire lobe, so that the signs will be likely to be limited 
to a space more or less circumscribed below the clavicle, when, if the 
affection were simple pneumonitis, the entire lobe would be soon in- 
vaded, and its boundary line determined by means of percussion and 
auscultation to be in the situation of the interlobar fissure. Hemor- 
rhage will be likely to occur in connection with tuberculous disease, 
and not in pneumonitis, except in so far as it enters into the produc- 
tion of the rusty sputa. The lancinating pains in phthisis are gene- 
rally referred to the summit of the chest, or are seated beneath the 
scapula, not fixed in a point at or near the nipple, as in pneumonitis. 
The characters of the pulse in '' tuberculous fever" differ from those 
which belong to the febrile movement symptomatic of an acute local 
inflammation. In the former the pulse is often very frequent, vibra- 
tory or thrilling, denoting irritability rather than increased force in 
•the ventricular contraction. In the latter it is less rapid, but stronger, 
indicating abnormal power in the action of the heart. Rapid loss of 
weight characterizes acute phthisis. Diarrhoea frequently occurs. 
The patient, notwithstanding the greater frequency of the pulse, and 
with an equal, if not greater disturbance of the respiration than ordi- 
narily attends pneumonitis, does not yield to the disease and take to 



430 DISEASES OF THE RESPIRATORY ORGANS. 

the bed, as when attacked with pneumonic inflammation. Acute 
phthisis, when it is most rapidly developed, does not present the 
abrupt access which generally characterizes cases of pneumonitis. 

The differential diagnosis may be more difficult when the tubercu- 
lous deposit, in deviation from the laws of the disease, takes place 
first at the base of the lung, and gradually extends upward. This 
anomalous form of tuberculous development, according to the obser- 
vations of Dr. H. I. Bowditch, occurs in a ratio of 1 to from 150 or 
200 cases.-^ The greater liability to error of diagnosis in this variety 
of phthisis arises from the physical signs being manifested in the 
aamc situation as in most cases of pneumonitis, viz., on the posterior 
surface of the chest, especia% below the scapula, and also from the 
presence of the crepitant rale, which was observed in seven of eight 
cases reported by Dr. Bowditch. The combination of physical signs, in 
fact, may be precisely that which characterizes pneumonitis. The 
incongruousness of the associated symptoms, on the supposition that 
pnumonitis exists, and the presence of certain of the traits significant 
of phthisis, point to the nature of the disease. With the physical 
signs just mentioned, patients preserve strength sufficient to be up 
and out of doors. The disease even if rapidly developed is always 
more gradual than pneumonitis. Hemorrhage occurs in a certain 
proportion of cases. The ragged opaque sputa of phthisis are some- 
times observed. Acute symptoms are by no means uniformly present 
in this variety of tuberculous disease. The crepitant rale is persis- 
tent, continuing for wrecks and even months. Although, therefore, 
the combination of physical signs and their situation are the same as 
in pneumonitis, the associated circumstances and the progress of the 
disease present points of disparity which speedily lead to the correc- 
tion of an error in diagnosis, liable to arise from inadvertency or a 
premature conclusion. 

(Edema of the lungs extending over one or more lobes may give 
rise, to some extent, to the physical signs incident to the stage of 
solidification from pneumonitis. Over oedematous lung there will be 
dulness on percussion, with, possibly, bronchial respiration, broncho- 
phony or exaggerated vocal resonance, and fremitus. These auscul- 
tatory phenomena, however, are rarely marked, and often absent. A 
well-marked crepitant rale is sometimes observed, but the sub-crepi- 
tant is much oftener present. (Edema occurring always as a secon- 

* Cases of anomalous development of tubercles, etc., by Henry I. Bowditch. Ameri- 
can Medical Monthly, N. Y. 1855. 



ACUTE LOBAR PNEUMONITIS. 431 

darj affection, from hypostatic congestion in fevers, from a changed 
condition of the blood leading at the same time to serous infiltration 
in other parts, from the obstruction proceeding from disease of heart, 
etc., its existence may be presumed when the physical signs denoting 
solidification become developed in those pathological connections, 
without being preceded or accompanied by the symptoms of acute 
pneumonitis. Moreover, the causes producing the oedema acting 
equally on both lungs, the local evidences of the solidification in a 
certain proportion of cases, although not generally, are found on each 
side of the chest. 

An oedematous condition may occur as a sequel of pneumonitis in 
the portion of lung which has been the seat of the inflammation. 

SUMMARY OF THE PHYSICAL SIGNS BELONGING TO ACUTE LOBAR 
PNEUMONITIS. 

The vesicular percussion-resonance diminished during the stage of 
engorgement, but in a more marked degree after solidification has 
taken place ; sense of resistance notably increased ; the limits of the 
dulness and loss of elasticity corresponding to the boundaries of the 
affected lobe ; the vesicular resonance often replaced by a tympanitic 
sonorousness, more or less marked ; the crepitant rale generally dis- 
covered by auscultation, accompanied or followed by the broncho- 
vesicular and the bronchial respiration ; bronchophony and exagge- 
rated vocal resonance generally present ; increased vocal fremitus 
over the solidified lung existing in a large proportion of cases, occa- 
sionally pectoriloquy ; an acute souffle, frequently intense, accompa- 
nying whispered words ; sub-crepitant rale during the resolution of 
the disease in some instances ; the moist and dry bronchial rales 
occasionally heard, but rarely prominent unless the disease advance 
to the stage of purulent infiltration, when the moist rales may be 
more or less abundant ; a friction-sound heard in a small proportion 
of instances ; on the unaffected side exaggerated respiration ; dimi- 
nished respiratory movements on the affected side sometimes apparent 
on inspection, if the affection be limited to a single lobe ; oftener 
observed, and in a more marked degree, if the inflammation extend 
over an entire lung ; contraction of the side affected after resolution 
in some cases. 



432 



DISEASES OF THE RESPIRATORY ORGANS. 



Lobular Pxeumoxitis. 



Lobular Pxeumoxitis ; Bronclw-Pneumonia ; Imperfect JEx- 
2)ansion {atelectasis) and Collapse of Pulmonary Lohules. — The 
term lobular -^-hen properly applied to cases of pneumonitis, implies 
that the inflammation, instead of extending over an entire lobe, 
is more circumscribed, being confined to lobules, either isolated or 
in clusters, "situated at different points, more or less numerous, and 
disseminated usually over the pulmonary organs, on both sides of 
the chest. It is only within a few years that the attention of patho- 
logists has been directed to the study of such a form of the disease. 
It was first fully described as a distinct variety of pnermionitis, 
occui-ring in children under six years of age, in this country by Dr. 
Gerhard,^ and in France by Dr. Rufz,^ Rilliet and Barthez,^ Yalleix,* 
and others. As described by the writers just mentioned, lobular 
pneumonitis embraces all cases in which, after death, the lungs are 
found to present solidified portions (exclusive of solidifications from 
tubercle or other heteromorphous deposits), varying in size from a 
pea to a filbert, scattered irregularly, occasionally confined to one 
side, but much oftener distributed over both luno:s, varvinor in number 
from 2 to 30 ; the intervening parenchyma preserving the characters 
of the normal spongy tissue. This pathological condition in a large 
majority of instances is associated with the anatomical characters of 
bronchitis, and hence the affection is often called broncJio-pneumonia, 
a term first ap2:)lied, in 1S3T, by a German author, Seifert. 

Researches still more recent have shed new light on the morbid 
anatomy and the pathology of affections heretofore, and still to a 
greater or less extent, included under the appellation of lobular 
pneumonitis and broncho-pneumonia. In 1832, Prof. Jorg, of Leip- 
sic, published an account of a morbid condition found in the bodies 
of newly born children, analogous to that regarded as characteristic 
of lobular pneumonitis, which he attributed to imperfect expansion 
of the lungs by the fii'st inspirations after birth ; in other words, more 
or less of the lobules remaining in the foetal state. To this morbid 
condition he applied the title of atelectasis. This condition had been 
previously described by a French writer, M. Duges, in. 1821, in a 
thesis which failed to attract attention to the subject. The anato- 

' Am. Jour, of Med. Sciences, 1S34. ' Journ. des Conn. Medico-chinirg. 1S35. 

' Traite des Maladies des Enfans. ^ Traite des ^Maladies des Enfans nouv. nes, 1S33. 



LOBULAR PNEUMONITIS. 433 

mical characters regarded as distinctive of a persisting foetal condition, 
are as follows : — the solidified lobules giving rise to depressions on 
the surface of the lung ; the pleural covering retaining its glistening 
polished aspect ; the size of the lobules affected, and the lobe in 
which they are found not augmented, but diminished ; the cut sur- 
faces, when the solidified lobules are incised, wanting a granular 
appearance, smooth like muscle, and the tissue not softened or friable 
as it is in the second stage of ordinary pneumonitis. The morbid 
appearances, in other words, are those which belong to the condition 
called carnification. An important point of evidence, according to 
Jorg, of the morbid condition called by him atelectasis, was, that by 
insufflation the condensed lobules were found to be capable of being 
brought to a normal condition.^ 

Still more recently, the researches of MM. Legendre and Bailly, 
of Paris, demonstrated that, in a certain proportion of the cases of 
so-called lobular pneumonitis, in which the affection is developed at 
a period more or less removed from birth, the affected lobules are in 
a condition analogous to that of foetal life : that is to 3ay, the charac- 
ters pertaining to the condensation are those of carnification as 
distinguished from red hepatization, and the fact that the air vesicles 
are not occluded by a solid deposit, as in cases of ordinary lobar 
pneumonitis, is shown by the solidification being removed by insuffla- 
tion. The authors just named first suggested this simple test of the 
condensation occasioned by morbid causes acting after birth, being 
due to a return to the foetal state, although the same means had 
been previously resorted to by Jorg in cases of supposed atelectasis.^ 

The distinctive appearances of the parts in the one case preserving, 
and in the other case resuming a foetal state, had by no means 
escaped the notice of earlier writers on the subject of lobular pneu- 
monitis. They had, however, attributed the production of this 
morbid condition to inflammation, attributing the differences in the 
anatomical characters — absence of the granular deposit, want of 
friability, etc., to modifications of the inflammatory processes peculiar 
to early life. The investigations of Jorg, and Legendre and Bailly, 
tend to the conclusion that the cases of so-called lobular pneu- 
monitis, in which the lobules are in the foetal state, or carnified, 

^ The cases given by Valleix and others of lobular pneumonitis in still or newly born 
children, supposed to have existed in intra-uterine life, were probably cases of atelec- 
tasis. 2 Archives Centrales de Medecine, 1848. 

28 



484 



DISEAS 



ATOBY OR&AMS. 



do not involve the existence c: iiz liii :: n of the air-cells or paren- 
chjma, and tliat they are not pre:: t ~ -es of pneumonitis. 

This subject at the present mocirL: ^ ::ie of the most interesting, 
and perhaps one of the most important of those with which patholo- 
gical inquirers are occupied. I>r. Euchs of Leipsic, and Dr. W. T. 
Gairdner of Edinburgli, have published facts tending to show that 
condensation of more or less of the pulmonary lobules ofiten occurs 
as the effect of collapse of the air-ceUs, due to partial obstruction of 
the bronchial tubes from accumulation therein of inflammatory pro- 
ducts ; and in proportion as so-called lobular pneumonitis consists of 
cases of solidification thus produced, the lesion is, in fact, incident to 
bronchitis, and is not rightly called either lobular pneumonitis, or 
broncho-pneumonia. As a complication of broncbial inflammation, 
lobular collapse has been already referred to in connection with the 
consideration of bronchitis. The researches of Dr. Gairdner render 
it probable that coBapse of portions of the lung is by no means an 
event exclusively pertaining to early life, and that bronchial obstruc- 
tion sustains an important pathological connection with an affection 
to be next considered (emphysema). It is, however, entirely foreign 
to the plan of this work to engage in inquiri^ or discussions relative 
to questions which concern the aetiology of the diseases affecting the 
r^piratoiy organs, their pathological character and relations, except 
so far as such questions are nece^arily involved in the subject of 
diagnosis. In the present instance, the very brief history which has 
been given of the recent scientific developments pertaining to lobular 
pneumonitis, has seemed to be requisite for a proper understanding 
of the affections which are to be included under this caption. In 
the existing state of pathological views, I do not deem it advisable 
to treat, in this work, of atelectasis, coUapse of the lung, and true 
lobular pneumonitis, under separate heads. I shall notice them, 
severally, as falling within the divi^on of pneumonitis, entitled 
lobular, wishing it, however, to be fully understood, that this course is 
adopted for the sake of convenience, and, it may be added, expe- 
diency, in view of the importance of further investigations as the 
basis of settled nosological distinctions.^ 

' The leader de^ioos of beconiiiig acqnaintted irhh zecent Tiews and lesearclies 
lelatiBg to the dilerrait morbid coDdidons heietofiire inchided under die appellafioa 
laboHar pneunumilis, maj ccmsnlt tiridi adTantage, in addisiaii to die pablicatioos already 
cited. Basset FaSh. AnaL ; West on the Diseases of Qiildxen ; Beview of Dr. Gairdner 
in llie ^^t. and For. Med. Chir. Review, April, 1853, and a poblicaticn by the same 
anttc rr.:-:"rl ' : r Padiologieal Analoary of Bronchitis, and the Diseases of die 
La- z : : . : f I - =hial Otetraction,*' Edinbnrgh, 1850. 



LOBULAR PNEUMONITIS. 435 

Collapse and true lobular pneumonitis, although peculiarly infan- 
tile affections, are by no means exclusively confined to early life. 
Collapse, it is probable, may take place at any age. and according to 
the observations of MM. Hourmann and Dechambre,' it occurs not 
infrequently in the aged. On the other hand, the pneumonitis 
occurring secondarily in cases of purulent infection of the blood, 
may be said to be lobular. 

Physical Signs and Diagnosis. — In cases of imperfect expansion, 
or atelectasis, dulness on percussion is a physical sign frequently 
available. The existence of condensed lobules in both lungs is an 
obstacle in the way of a comparison of the two sides ; but the con- 
densation being usually more extensive on one side than on the other, 
a disparity in the percussion-resonance may be obvious. A greater 
relative dulness will oftener be found on the right, than on the left 
side, the right lung being more apt to suffer from defective expansion. 
A judgment, however, may be formed, to some extent, of an abnor- 
mal deficiency of resonance on both sides, irrespective of a comparison 
between them, the sound being manifestly more dull than if the cells 
were fully expanded. Feebleness or absence of respiratory sound 
will be likely to be the result obtained by auscultation. The force 
of the respiratory movements is probably inadequate, in most in- 
stances, to develope the bronchial or even a well-marked broncho- 
vesicular respiration, the existence of which in view of the solidifica- 
tion, might be rationally anticipated. Over the non-solidified portions 
of lung, the vesicular murmur, instead of being supplementarily ex- 
aggerated, will be abnormally feeble, owing to the same cause, viz., 
the weakness of the inspiratory efforts. The latter is also consistent 
with the fact that, for some time after birth, in health, the vesicular 
murmur is feeble, although subsequently it acquires an intensity, 
afterward again lost, constituting what is known as the puerile respi- 
ration. Inspection shows the visible movements of respiration to be 
unnaturally feeble, the type of breathing being abdominal ; and it 
has been pointed out by Dr. George A. Rees of London, that the 
lower ribs, instead of expanding with the descent of the diaphragm, 
contract during the act of inspiration, from the outward pressure of 
the atmosphere, upon the condensed lung. 

With these signs, taken in connection with the symptoms which 
have been mentioned, the diagnosis of imperfect expansion or atelec- 
tasis may be made with much positiveness. 

' Archives G^n^rales de Medecine, 1835 and 1836. ^ 



486 DISEASES or the eespibatokt orgams. 

In cases of lobular condensation ft«m eoEapse, if it be sufficient in 
extent to give rise to considerable embarrafism^it of respiration, per- 
cussion may be expected generally tx> famisb evidence of the solidifi- 
cation. Tbe dnlness will, of course, be marked in proportion to tbe 
nnmber of lobules collapsed, and their proximity to the thorai^c waHis. 
Next to these conditions, the greater amount of eoHapee on one side of 
the chest, is the circumstance most important ia rendering the dnlness 
obvions by contrasting the percussion-sounds on the two sides. If 
the condensed lobules are in gmall disseminated cliiBters, and not 
far fi*om equal in both longs, the advantage of a comparison of the 
two sides is lost, and the fact of dnlness may not be determinable. 
The proportion of such instances in cases of collapse remains to be 
ascertained by numerical investigations ; hot it is probabfy not great, 
since it is rare to find a near approach to eqnality, in the amount of 
condensation existing in both lungs. 

The crepitant rale of pneumonitis do^ not, of course, belong to 
this form of disease. The fact that cases of collapse haTC hitherto 
been confounded with tme lobar pnenmonitis may senre to account 
in a measure (but by no means entirely, as will be presently seen), 
for the opinion that this rale is rarely heard in the latter afTectiim. 
Auscultation discovers more or less of the dry and mnoons rales 
in certain cases, but not uniformly. Collapse is not always, althongh 
probably in the large proportion of cases, associated with bron- 
chitis ; and, moreover, the bronchial rales are far from being con- 
stant in cases of bronchial inflammation. More or le^ of the 
characters of the bronchial or the broncho-Tesienlar respiration will 
be present in a certain proportion of cases ; but the numerical fre- 
quency of their occurrence, in common with other points pertaining- 
to the semeiological history of that affection, as distinguished :': : zi 
true lobular pneumonitis, is to be settled by future researches. Z'l- 
same remarks are alike applicable to increased Tocal resonance and 
fremitus, auscultatory signs less aTailable in young children, owing 
to the ateenee of their voluntary co-operation. The voice as mani- 
fested in crying must be the imperfect substitute for the method 
practised after speech is acquired, and the patient is of an age to 
employ it voluntarily for the benefit of the auscoltator. 

The suddenness with which the physical eridence of solidificatiim 
becomes developed, a part, for example, bdng found to be notably 
dull on percussion, when the day previous there was no apparent 
diudnntion of sonoreiiy, is a point possessing diagnostie importance. 



LOBULAR PNEUMONITIS. 437 

Its significance however, as distinguishing the condensation of collapse 
from that of pneumonitis, is less than it would be, if observations did 
not show solidification from inflammation in some instances to take 
place with great rapidity, a marked change in the percussion-reso- 
nance occasionally taking place within the space of twenty-four 
hours. 

As regards physical signs it must be admitted that, with our pre- 
sent knowledge, there are few very striking points which enable us to 
discriminate between the condensation from collapse, and solidification 
involving pneumonitis. The symptoms and attendant circumstances, 
taken in connection with the physical signs, have an important bear- 
ing on the diagnosis. Among the symptoms the absence of febrile 
movement is highly significant. The abrupt occurrence of difficult 
breathing and the evidences of defective hsematosis, is another point 
possessing a certain amount of significance. The state of the muscular 
power, at the time the vital and physical evidences of condensation 
became apparent, is to be considered. Occurring during great exhaus- 
tion, when the force of the inspiratory effort might be expected to be 
greatly reduced, the probability of collapse is certainly much greater 
than under opposite circumstances. And if, under these circum- 
stances, the symptoms of bronchial inflammation are absent, the 
chances are in favor of collapse, in view of the small proportion of 
instances in which, in children, true lobular pneumonitis occurs as a pri- 
mitive aff'ection, that is, independently of bronchitis. The difi'erential 
diagnosis is not simply a matter of scientific interest. The practical 
bearing is obvious, since the tAvo conditions may call for precisely 
opposite measures of therapeutics. Future clinical investigations may 
render the discrimination less a matter of inferential reasoning than 
it is at the present moment. 

In lobular pneumonitis the characteristic rale, viz., the crepitant, 
which, in the lobar form of the disease, aff'ecting adults, is an early 
and almost constant sign, fails to be observed in a certain proportion 
of cases. Eliminating the cases of collapse which have been hitherto 
considered to be cases of lobular pneumonitis, and the ratio of in- 
stances in which this rale is discoverable is much increased, but it is 
by no means uniformly or frequently present even in well-marked 
primitive lobar pneumonitis, occurring in the child. The probabilities 
of its existence are to be settled by future clinical observations. 
When present, it has the same significance as in cases of pneumonitis 
afi'ecting the adult. It is nearly pathognomonic. It is therefore to 



438 DISEASES OF THE RESPIRATORY ORGANS. 

be sought for with care, and by patience it may sometimes be heard 
at the end of an unusually deep inspiration, such as occurs in con- 
nection with a fit of coughing, when in ordinary breathing it is not 
appreciable. It may be developed during a short interval separating 
successive examinations, owing to inflammation having in the mean- 
time extended to new portions situated nearer the surface of the lung. 
It may be observed or drowned by the bronchial rales incident to ante- 
cedent and coexisting bronchitis. 

Dulness on percussion may not be apparent while the inflamed por- 
tions are but few in number, small and centrally situated. When, 
however, the solidification has extended over a certain space, the per- 
cussion-resonance is obviously impaired. The advantage of contrast- 
ing the two sides is oftener available in cases of solidification from 
inflammation, than from collapse, because in the former instance it is 
more likely to be limited to one lung. An increased sense of resist- 
ance on percussion, will serve to confirm the fact of relative dulness 
on one side. 

The broncho-vesicular and a well-marked bronchial respiration 
oftener accompany lobular pneumonitis than condensation from col- 
lapse, owing to the greater force of the respiratory movements in the 
former afi'ection. The same remark is equally applicable to exag- 
gerated vocal resonance and fremitus, manifested in connection with 
the cry of the patient. 

For a similar reason the existence of supplementary respiration in 
healthy portions of lung, will be likely to distinguish this form of 
disease from collapse. A greater activity of the respiratory move- 
ments will also be apparent on inspection. 

The points pertaining to physical signs just mentioned, in addition 
to those belonging to the history and symptoms, will assist in the 
discrimination of lobular pneumonitis from collapse. 

Lobular pneumonitis is to be clinically discriminated from other 
affections. In cases of ordinary acute bronchitis, the question will 
sometimes arise, whether the afi'ection be bronchitis simply, or bron- 
cho-pneumonia. The former, as has been seen, often merges into 
the latter. The circumstances indicating an extension of the inflam- 
mation to the parenchyma are, acceleration of the breathing, with 
dilatation of the alae nasi ; circumscribed flush of the cheeks ; increased 
febrile movement. To these symptoms may be added, the crepitant 
rale in some instances, this, of course, rendering the diagnosis as 
complete as possible. Exclusive of this sign, if dulness on percussion 



LOBULAR PNEUMONITIS. 439 

be well-marked, the diagnosis lies between pneumonitis and collapse ; 
and the associated signs and symptoms, taken in connection with the 
history, will frequently, if not generally, enable the practitioner to 
arrive at a decision. 

The discrimination is also to be made between lobular pneumonitis 
and capillary bronchitis. The latter is a much graver form of dis- 
ease. The respirations are more hurried ; the dyspnoea more in- 
tense ; the evidences of imperfect haematosis greater ; the circulation 
more disturbed. Percussion, if the affection have not induced col- 
lapse of more or less of the pulmonary lobules, elicits everywhere 
over the chest a clear resonance ; and, at all events, solidification, if 
it exist, is insufficient in extent to account for the extreme disorder 
of the respiration and the circulation. The crepitant rale is want- 
ing ; but the sub-crepitant is extensively diffused over both sides of 
the chest. Due attention to these points will render the differential 
diagnosis, in general, not difficult. 

Some cases of acute phthisis in young children, may present cha- 
racters derived both from symptoms and signs, causing it to simulate 
lobular pneumonitis. It is well known that in children the tubercu- 
lous deposit takes place frequently with great rapidity, and, as 
regards situation, does not obey the law, in accordance with which, 
in adults, the superior portion of the upper lobe is first affected in 
the vast majority of cases. So also the law which determines the 
seat of pneumonitis in the inferior lobe with rare exceptions, does 
not apply to the same extent to the child. These deviations impair 
the facility of diagnosis. The physical signs attendant on solidifica- 
tion from tubercle are essentially the same as in consolidation from 
inflammation. Bronchitis and febrile movement may accompany 
both affections. Moreover, the two affections may be combined, con- 
stituting what pathologists have called tuberculous pneumonia. The 
circumstances attending the development of the disease, and its pro- 
gress, which belong to the history of phthisis, and the prior condi- 
tion of the patient as regards a constitutional tendency to that dis- 
ease, together with the positive indications of a tuberculous diathesis, 
in cases of doubt, must be relied upon in making the discrimination. 
These points cannot be here considered without anticipating subjects 
belonging to another chapter. 

Lobular pneumonitis is not unfrequently overlooked, the patient 
being supposed to labor under some other affection. Thus the occur- 
rence of convulsions, and drowsiness, sometimes lead the practitioner 



440 



DISEASES OE THE EESPIEATOPtT OEGAXS. 



I 



to refer the chief malady to the head. Yomiting and diarrhoea, 
events of occasional occurrence, may cause the attention to be con- 
centrated on the alimentary canal. The disease may be mistaken 
for infantile fever. These errors of diagnosis are chargeable on a 
want either of proper knowledge or attention. The discrimination 
does not involve sufficient real difficulty to require that the differen- 
tial diagnosis should be formally considered. 



Chroxic Pxeijmoxitis. 



Following the example of wiiters generally, who have treated of 
diseases affecting the respiratory organs, I shall dispose of the sub- 
ject of chronic pneumonitis in a summary manner. Our knowledge 
of this form of disease is imperfect. Laennec questioned its exis- 
tence. Xearly all pathological observers are agreed, as respects the 
infrequency of its occurrence, and different opinions on this point 
may be in a great measm-e accounted for by difference of views as to 
the morbid conditions to which the name of chronic pneumonitis is 
properly applied. Some writers (Andral. Hasse), who regard it as 
not very uncommon, embrace under this title certain cases of tuber- 
culosis characterized by solidification of the pulmonary parenchyma 
between the tuberculous deposits. Under these circumstances the 
morbid condition, admitting it to be chronic pneumonitis, is inci- 
dental to tuberculosis, and it is not, therefore, to be considered a 
separate form of disease. It is probable that cases of collapse have 
been sometimes set down as instances of chronic pneumonitis. For 
example, a case reported by M. Kequin, and detailed by Grisolle,^ 
in which the lower lobe of the rio^ht lung was found after death 
firmly condensed, non-granular, without tubercles or miliary granu- 
lations, may be suspected to have been of that description. The same 
remark wiQ apply to cases of carnification supposed to result from 
chronic inflammation of the pulmonary parenchyma. An instance 
of this kind is quoted by Grisolle, from MM. Eiiliet and Bai'thez. 

According to Rokitansky, the morbid condition characteristic of 
chronic pneumonitis consists iu the presence of inflammatory exuda- 
tion withiu the areolar tissue uniting the pulmonary lobules, and the 
smaller groups of air-cells, and he applies to this form of disease the 

- Traite Prarlque de la Pne-arDonie. p. 351. Tiiis case is referred to bv Dr. Walshe. 
under the head of Chronic Piier.moDia. 



CHRONIC PNEUMONITIS. 441 

title of interstitial pneumonia. This infiltration within the inter- 
stitial tissue, he states, in the progress of time becomes organized and 
coalesces with the latter, so as to form a dense cellulo-fibrous sub- 
stance, which compresses and obliterates the air-cells, leading to con- 
traction of the thorax and dilatation of the bronchial tubes. This is 
essentially the form of disease described by Corrigan, and designated 
by him cirrhosis of the lung, to which reference has been made in 
connection with the diagnosis of dilatation of the bronchise. 

As a sequel of acute inflammation, chronic pneumonitis is exceed- 
ingly rare. Grisolle in his treatise giving the results of the analysis 
of 373 cases of pneumonitis, states that he has met with but a single 
instance in which the acute terminated in a chronic form of the dis- 
ease. M. Barth found but a single instance in a collection of 125 
cases of acute pneumonitis.^ It is true that frequently after acute 
inflammation the physical evidences of solidification continue for 
some time, not disappearing entirely for weeks or even months. It 
would, however, be incorrect to say that under these circumstances 
the disease was perpetuated in a chronic form. In cases of veritable 
chronic pneumonitis succeeding the acute disease, the acute symptoms 
disappear, but more or less febrile movement continues, occurring in 
paroxysms, or with marked exacerbations. Cough and expectoration 
persist, the latter not preserving the characters significant of the 
acute disease ; the respiration is accelerated, with dyspnoea ; the 
appetite does not return, or if it returns speedily fails ; the patient 
loses strength and weight, and, at length dies, after the lapse of 
two or three months. The physical signs of solidification persist 
during the progress of the chronic disease, viz., notable dulness on 
percussion, with bronchial respiration, increased vocal resonance, and 
fremitus, etc. In the case reported by M. Requin, above mentioned, 
the auscultatory phenomena denoting solidification, viz., bronchial 
respiration and exaggerated vocal resonance, were wanting. This 
occasionally happens in acute pneumonitis. Whether it is more likely 
to occur in the chronic form of the disease, it is impossible to say, in 
view of the very limited number of cases of the latter which have 
been reported. 

It is evident from the foregoing brief account of chronic pneumo- 
nitis that except so far as it is involved in a lesion already considered, 
viz., dilatation of the bronchise, it is an afi'ection possessing compara- 
tively small interest and importance in a practical point of view. 

^ Valleix, op, cit. 



442 



DISEASES OF THE RESPIRATORY ORGAXS. 



Although the physician is yery rarely called upon to make the diag- 
nosis, the fact of its occasional occurrence is not to be lost sight of. 
In cases in which, after acute pneumonitis, physical signs denoting 
solidification are found to remain, associated with symptoms which 
indicate a graye malady, yiz., febrile exacerbations, loss of strength 
and weight, cough and expectoration, etc., the question may arise 
whether the patient be afi'ected with chronic pneumonitis or tubercu- 
losis. If the physical signs denote solidification of the upper lobe, 
and especially if they denote that the solidification is confined to the 
upper portion of the lobe, the chances against the existence of tuber- 
cle are exceedingly small. The chances are greatly increased if the 
local afi"ection be seated in the lower lobe ; but this situation is not 
conclusiye evidence against the existence of tubercle, for, as exceptions 
to the general law, the tuberculous deposit in some instances takes 
place fii'st in the lower lobe. The difi"erential diagnosis rests mainly 
on the presence or absence of the events characteristic of the progress 
of tuberculous disease, viz., haemoptysis, pleuritic pains, nocturnal 
sweats, etc., together with the physical evidences of the loc^l changes 
incident to phthisis, viz., softening of the tuberculous matter and the 
formation of cavities. 



CHAPTER IV. 

EMPHYSEMA. 

The term emphysema is used to designate two quite different pul- 
monary affections. In one of these affections the morbid condition 
consists in an abnormal increase in size of the air-cells, and conse- 
quent over-accumulation of air within them. This is by far the more 
frequent in occurrence of the two affections, and is generally under- 
stood when the word emphysema is applied without any qualification 
to a morbid condition of the lungs. The term is manifestly inappro- 
priate, since there is only a remote analogy of the pulmonary affec- 
tion, to the extravasation of air into areolar structure, the latter being 
the morbid condition designated by emphysema w^hen it is used with- 
out special reference to the pulmonary organs. Dilatation of the 
air-cells, and rarefaction of the lung, are titles more expressive 
of the morbid condition, and are to be preferred. Vesicular emphy- 
sema and true pulmonary emphysema, are expressions employed by 
Laennec and subsequent writers to distinguish the affection now 
referred to. 

The other affection to which the name of emphysema is applied, 
consists in the extravasation of air into the areolar structure uniting 
together the pulmonary lobules, and connecting the pleura with the 
superficies of the lung. This morbid condition, more correctly than 
the first styled emphysematous, is distinguished as i7iterlohular and 
suh-pleural emphysema. 

These two forms of the disease claim separate consideration ; but 
the latter will require comparatively brief space. 



I. Yesicular Emphysema. 

Yesicular Emphysema ; Dilatation of the Air-cells ; Rarefac- 
tion of Lung. — Laennec was the first to give a clear description of 
this affection ; and in view of the originality and value of his researches, 



444 DISEASES OF THE RESPIRATORY ORGANS. 

a distinguished morbid anatomist of the present day,^ has said that 
" had Laennec done nothing else for medical science, his discovery of 
this diseased condition, and of the causes giving rise to it, would have 
sufficed to render his name immortal." The pathological relations 
of dilatation of the air-cells, and the mode in which the lesion is pro- 
duced, are subjects of great interest and importance, which at the 
present moment are under discussion, and concerning which conflict- 
ing opinions are maintained by different writers. Conformity to the 
plan of this work renders it necessary to forego any consideration of 
these subjects, limiting the attention to the physical signs and the 
diagnosis of the affection.^ 

Physical Signs, — Dilatation of the air-cells is accompanied by 
physical signs which, combined, are quite distinctive of the affection. 

Percussion elicits, with few exceptions, an exaggerated sonorous- 
ness. The resonance is deficient in vesicular quality. The pitch is 
raised. The sound, in other words, without becoming purely tympa- 
nitic, acquires more or less of the tympanitic character ; it is vesiculo- 
tympanitic. This abnormal modification is more marked, of course, 
when the emphysema is limited to one side, being contrasted with 
the normal resonance on the unaffected side. The emphysema, how- 
ever, when it exists on both sides, being usually greater on one side 
than on the other, a disparity between the two sides is apparent. 
Under these circumstances, the vesiculo-tympanitic character of the 
sound is generally obvious on both sides, but this character is more 
strongly marked on the side which, at the same time, presents other/ 
signs significant of a greater amount of dilatation of the air-cells. 
Occasional exceptions to the rule of exaggerated resonance are ob- 
served. In a single instance, the emphysema existing on both sides, 
but greater on the right side, I have noted that the sonorousness on 
the left side exceeded that on the right, the resonance being less 
vesicular and higher in pitch on the right side. It is to be borne in 
mind, that a natural disparity as respects the points just named exists 
in many persons. 

^ Rokitansky. 

2 The author cannot forbear referring the reader to the late views respecting the 
pathological relations and the production of dilatation of the cells, which have been 
advanced by Dr. W. T, Gairdner of Edinburgh. These views are certainly highly inte- 
resting and ingenious, if they are not destined to effect a radical change in the opinions 
commonly held on these subjects. Vide Brit, and For. Med. Chir, Review, April, 1853 ; 
or a treatise entitled " On the Pathological Anatomy of Bronchitis, and the Diseases of 
the Lung connected with Bronchial Obstruction." Edinburgh, 1850. 



YESICULAE EMPHYSEMA. 445 

The sense of resistance is increased over emphysematous lung in 
proportion to its increase of volume. In cases in which the chest is 
partially or generally enlarged, this sign, incidental to the act of per- 
cussion, is present in a marked degree. 

An unnatural clearness of resonance is found in the prascordia, espe- 
cially if the left lung be affected. The heart may be removed from 
contact with the walls of the chest, and carried downward, so that be- 
tween the sternum and nipple, the chest becomes highly resonant. 
If the emphysema be general, or affect the lower lobes, the pulmonary 
resonance extends below its normal limits, toward the base of the 
chest. For example, on the right side, in front, the line of hepatic 
flatness may be depressed to the ninth or tenth ribs on a vertical line 
through the nipple ; and, owing to the permanent expansion of the 
lung, this line is found to vary but little with the successive acts of 
inspiration and expiration, even w^hen they are voluntarily increased. 
A similar extension of the space occupied by pulmonary resonance, 
is apparent on the lateral and posterior surfaces of the chest at the 
base, and also at the summit, in some instances, above the clavicle, 
and at the upper part of the sternum, where, from its relation to the 
trachea, the normal resonance is tubular. In cases in which the em- 
physema is confined to one side, if the volume of the lung be conside- 
rably augmented, the exaggerated vesiculo-tympanitic resonance ex- 
tends beyond the median line on the opposite side, in consequence of 
the lung exceeding laterally its normal limits and encroaching on the 
space belonging to its fellow. 

The auscultatory phenomena due to the emphysema are to be dis- 
tinguished from those attributable to bronchial inflammation or catarrh 
which so frequently coexist. Exclusive of those to which these com- 
plications give rise, the signs pertaining to the respiration are, in 
themselves, highly characteristic of the affection, and in combina- 
tion with the evidence derived from percussion, their diagnostic signi- 
ficance is quite positive. Feebleness of the respiratory murmur is 
one of the distinctive features. In some instances a respiratory 
sound is inappreciable with the ordinary stethoscope or by immediate 
auscultation, and is scarcely heard with Cammann's instrument. 
Other things being equal, the feebleness is proportioned to the degree 
of the emphysematous condition. When both lungs are affected, but 
one lung more than the other, a disparity will be found to exist be- 
tween the two sides in this particular ; and the greater feebleness of 
respiratory sound, is on the side presenting the greater clearness and 



M3 



DISEASES or THE BESPIHATOmY OaeAJT! 



tyiHpaiiitie quality €^ ipssteimmmr^r&xmaxuBR. The resBf^raimj 
maj he almoglt car qoiie mdl mt lids side, and liie inteii^ij relalwe!^ 
gnealier tm. liie o^i^, Imt; mflre or le^ below tlie nofnaal amoonlL Chi 
Ihe other liand, if the emphjsema, be liiiiiled to cme famg, tibe le^irar 
tray sound efnanaliiig fimn Ibe csdiei'lniig ifdilbe liki^to exceed tbe 
n onoal interasiltj^ in oilier word% be so^pknieiitazily exa^raated. 
An exa^eiated iie^iialiiHi maj aho eiist on the aflEeeted ^ide or 
sides, OT^" tdbe prationB of hmg to wiaeh the cii^^hjsenia. does not ex- 
tend. Whmt Ihe em^jssma, h cora£ned to the i^per lobe, Ihe lespi- 
ratoij mnnnnr below ithe seapnla, bdbind, will be found to be in a 
markafl degiee more intoase Ihan at Ihe iBionmit in £roal^ Ihe lewerse 
being the ease in health. 

The T^piiatray sound is altered in other lespeets Ihan infciMwIj. 
It M changed in ihjthm. ^be ini^ratiamL is shortened, lllie ina^si- 
latray sound m de^Exred ; that iSy n&ore or less of the n^^oratoiy act 
takes plaee before Ihe scmnd h appredable. Simidtimes a toj brief 
sound only is heaid at the elose <if Ihe aeL The expiratory sound, 
<m Ihe other hand, is o£ten prohno^ed, fineqjuentij exceeding eonsdde- 
labfy in doralion Ihe sound of inspralion. Tlie expiatory sound is, 
always uMHe or less feeble ; but ils intensity may be greater Ihan Ihat 
of the sound of inspiralion. Hie latter may be almost inappredable 
wMIe Ihe form^' is distinetly allhou^ Cunliy heard. 

The respiratory sound also undeigoes a. change in quafity. It is 
said to become f%>]^JL The in^iratray sound has l^s of Ihe iredieular 
quality Ihan belong to Ihe nonnal murmur, and m ra^ed in |Htdi. 
So £sr it preseolB Ihe characters of Ihat almormal modificatioraL gene- 
rally distingukhed as roMghmem. It difos, howewer, matefiaify from 
the bnmcho-^t'esiRdar resp&rnlioii incident to m mori^ csmdilion, Ihe 
oppodbte of rare&ction, TiiL, inoeased denaty of the pufanonaxy 
stmelnre. The prohmged expiration, if il be a pure re^iratoiy sound 
mthout an admixture of a ralalantrale, is lower in pitdi than Ihe sound 
of inspiration, while in a broncho-Teecular r^piralion due to eondeiisa- 
lion, Ihe pitch of Ihe prohmged expiratory sound m hi^ier Ihan Ihat 
of the sound of inspiration. In em^ysesnalhe e^ratoiy ib generally 
continuous willi the in^iratray sound. lii craidensation of lung a 
brief interval separate Ihe two sounds. The shortened ii 
empli^' : _ ' : : -^erred; in condensalifm it is wmjaMwim 

In ti.c l:.- , .idi^ of instances, at Ihe lime the al&scti 
tke ol^er^tion of Ihe ph^^ician, it m associated with brraadnilis, rar 
catarrh,, and frequently with brimchial spasm omstitnting an aHadc 



VESICULAR EMPHYSEMA. 447 

of asthma. Under these circumstances physical signs are present, 
due to the coexisting affections, but more or less modified by the em- 
physema. The moist bronchial rales are observed in a certain pro- 
portion of cases, consisting of the fine mucous or the sub-crepitant 
varieties, if the inflammation extend to the smaller tubes. Much 
oftener the dry rales are present — the sonorous or sibilant. The 
latter is heard more frequently than the former, but both are not un- 
frequently combined. In asthmatic paroxysms these rales are loud 
and diffused, accompanied by wheezing, which may be heard at a con- 
siderable distance from the patient. Exclusive of asthma, they denote 
either bronchial inflammation or irritation superadded to the emphy- 
sema. The rales often take the place of the respiratory sound, i. e. 
nothing else is heard. They are generally more marked in expira- 
tion than in inspiration ; and the sibilant are oftener heard than the 
sonorous, exclusive of the complication of asthma. 

Auscultation of the voice furnishes negative, or at least doubtful, 
results in cases of emphysema. Judging from my own observations, 
I would say that the vocal resonance does not, in general, undergo 
either marked increase or diminution in this affection. It is certain 
that if it be materially modified, the modifications are occasional, not 
constant. I have observed the naturally greater vocal resonance of 
the right side to be preserved when the emphysema was limited to 
the left side (as determined by other signs), and, on the other hand, 
I have observed the same natural disparity when the greater amount 
of emphysema was on the right side. Walshe states that intense 
bronchophony may exist over lung greatly rarefied. I cannot but 
suspect in such instances that it is due to a normal peculiarity, ex- 
isting irrespective of the emphysema. 

Auscultation in the prsecordial region, with reference to the pulmo- 
nary and cardiac sounds, affords a means, in addition to percussion 
and palpation, of determining whether the heart is abnormally over- 
lapped by lung, or displaced from its normal situation. The presence 
of a layer of lung between the organ and the thoracic walls may be 
shown by a feeble respiratory murmur, or the bronchial rales diffused 
over the whole of the prsecordia. The heart-sounds, under these cir- 
cumstances, are faint and distant. They may be inappreciable in the 
prgecordia, but if the displacement be downward toward the epigas- 
trium, they may be heard with distinctness in the latter situation. 

Inspection furnishes striking corroborative evidence of the exist- 
ence of emphysema. The frequency of respiration is often abnormal. 



448 DISEASE? OF THE SESPIEATOKY OEG-AXS. 

HabitnallY, if dyspnoea be absent, and the breatMng slightly or 
moderately labored, the number of respirations per minute may be 
found to be below the normal average. This may be the case if 
obstmction of the bronchial tnbes from bronchitis or spasm accom- 
panies the emphysema. Slowness of respiration, howeyer, by no 
means characterizes all cases of the affection. If the emphysema be 
sufficient to giye rise, of itself, to dyspnoea, whenever the circulation 
is accelerated, or from other causes, irrespectiye of bronchial obstme- 
tion ; and especially if the emphysema inyolye atrophy, as a predo- 
minant anatomical element, frequency of the respiration may be a 
prominent featxure. In a case of atrophous emphysema, I have ob- 
served the number of respirations, on exercise, increased to 60 per 
minute. 

In cases of general or extensive dilatation of the cells, the rhythm 
of the respiratory acts is altered, the deviation corresponding to that 
of the respiratory sounds. The inspiratory movement is shortened. 
The lungs being permanently expanded, the extent of their farther 
expansion with the inspiratory act, is proportionally lessened ; the act, 
therefore, is more quickly performed, and, moreover, if dyspnoea be 
present, the want of a fresh supply of atmospheric air causes the act 
to be hurried. The expiration, on the other hand, is prolonged in 
consec|uence of the impaired contractility of the pulmonary organs, 
and because more expiratory force can be exerted. When, in addition 
to the impaired contractility, the bronchial tubes are obstructed, which 
occurs if the emphysema be complicated with inflammation, irrita- 
tion, or spasm affecting the smaller bronchise, the expiratory move- 
ment is still more prolonged, owing to the obstruction offered to the 
passage of air from the cells. Under these circumstances, and, in- 
deed, from the impaired contractility of the lung alone, the labor 
and slowness with which expiration is performed, increase from the 
besdnninsr to the close of the act ; while in cases of obstruction to 

CO ^ 

the air-passages exterior to the lungs, the difficulty is manifested 
equally during the whole of the act of respiration. 

Certain characteristic signs pertain to the appearance of the chest 
while in rest and in motion. If both lungs are affected, and their 
volume be considerably augmented, the form of the chest is altered. 
The superior and middle thirds present an unnaturally rotmded. glo- 
bular, barrel-shaped appearance. Instances, however, in which the 
augmented volume of the lungs is sufficient to produce so striking 
an alteration are extremely rare. Partial enlargement between the 



VESICULAR EMPHYSEMA. 449 

clavicle and a point at or a little below the nipple, the degree of en- 
largement approaching to that of full inspiration is not uncommon. 
This abnormal fulness will, of course, be confined to one side, if the 
emphysema be thus limited. In cases in which both the lungs are 
affected, the abnormal prominence will generally be greater on one 
side than on the other, owing to the fact that the two lungs are 
rarely equally affected ; and as observations appear to show that the 
left lung is oftener more augmented in volume than the right, it will 
be oftener observed on the left side. In comparing the two sides 
with reference to this point, it is to be borne in mind, that normally a 
disparity exists in the anterior portion of the chest in many persons. 
According to the observations of M. Woillez, the left side presents a 
projection obviously greater than the right, above a point at or a little 
below the nipple, in about 26 per cent, of persons free from disease 
or deformity. It is not improbable that, owing to this natural dis- 
parity having been overlooked, a greater relative fulness of the summit 
of the left side may in some instances have been incorrectly attri- 
buted to a larger amount of emphysema on that side. A test of the 
prominence here or elsewhere, being due to the pressure of rarefied 
lung, is afforded by the results of percussion and auscultation. 

In some cases of emphysema the expanded lung effaces the depres- 
sion existing above the clavicle, causing a bulging in this situation. 
This, when present, is highly characteristic, but it is rarely observed. 

The inferior portion of the chest may appear to be considerably 
.contracted. This is in part apparent in consequence of the enlarge- 
ment of the superior portion, but it is, also, in some cases to a 
greater or less extent real ; the dimensions of the chest at its lower 
part are actually lessened. On the other hand, the upper part of 
the abdomen may acquire an unnatural fulness, and resistance to 
pressure, owing to the flattening of the diaphragm, which presses 
downward and outward, the organs lying below it. 

A close examination of the expanded portion of the chest shows 
the same relations of its different parts which obtain in health after 
a full inspiration, viz., the obliquity of the ribs is diminished ; the 
ribs and costal cartilages are nearly on one line ; the shoulders are 
raised; the intercostal spaces are narrowed at the summit, and 
widened over the middle of the chest. 

Patients who have suffered long from emphysema, generally pre- 
sent spinal curvature more or less marked. The dorsal curve is in- 
creased ; the lower angles of the scapulae project, and, hence, a 

29 



450 



I'l 



EESPIRATOBY ORGAFS. 






stooping gait is somewhat cbaracteristic. I: 
times highl J marked. 

The condition of the intercostal spaces in parts of the chest en- 
larged bj the distension of emphysematous long, has been a mooted 
points According to I>r. Stokes, the effect is never to efface the de- 
pression between the ribs. Obseiration, howeyer, appears to hare 
established, what would rationaQj be expected, that at the summit 
of the chest the intercostal muscles yield to the pressure of the lung 
n lily than the ribs, and hence, that the depressions in per- 

5: :: ~1:~ &ey are risible in this situation in health, become 
liiiii^ -_7 .... :i not effiiced. That this is rarely obserred at the lower 
part of the chest in &ont and laterally, where the depressions are 
most conspicuous, is true. One reason for diis is, that the emphy- 
sema is generally limited to or is much greater at the upper portion 
of the lungs. Another reason is, that traction of the diaphragm 
renders the depressions deeply marked during inspiration, not- 
withstanding the increase of the Tolume of the lung. In a case of 
emphysema limited to one side, not attended by dyspncea, or labored 
respiration, I hare obserred Ae antero-lateral intercostal depressions 
at the lower part of that ade abolished, presenting, in this particnlar, 
an appearance Teiy similar to that caused by the distension of the 
chest by liqnid in the pleural sac, and, in fact, prior to the case com- 
ing under my obserration, the patient was supposed to be affected 
with chronic pleurisy. 

Characteristics relating to the movements of the chest are not less 
striking than those incident to alterations in size and configuration. 
When the augmented volume of the lung is sufficient to keep the 
chest permanently dilated at a point not much below the limits of a 
fiall inspiration, of course the range of expansive movement in respi- 
ration is correspondingly restrained. The thoracic walls at the 
superior and middle portions contract but littie with expiration, and 
the enlargement with inspiration is slight. The dvspncea, however. 
especially when increased by any superadded cause affectiiig hiema- 
tosis^ such as exercise, the existence of bronchitis, or bronchial spasm, 
^ves rise to extraordinary efforts to expand the chest. The effect of 
these efforts, so far as they are exerted on the thoracic walls, is to 
eLevate the ribs ; and, as the costal cartilages are already straight- 
ened by the permanent expan^on, the elevation of the ribs carries 
the sternum npward, so that the whole chest, including in some in- 
stances the claricles, rises and falls with successive respiratory acts, 
as if it were a solid bony case. 



VESICULAR EMPHYSEMA. 451 

The diaphragm participates in these exaggerated efforts ; but if 
the emphysema extend to the lower lobes, the range of the diaphrag- 
matic movement is diminished, and the rising and falling of the 
abdomen is less than in health. If the emphysema be accompanied 
by bronchial obstruction, the lower part of the sternum, the epigas- 
trium, and inferior portion of the chest, laterally, are depressed with 
inspiration, the natural movements being reversed. This arises from 
the depression of the diaphragm elongating the lung, producing a 
vacuum which is not filled with sufficient rapidity by the air received 
into the bronchial tubes, and consequently the weight of the atmo- 
sphere presses the walls of the chest inward. This is less marked in 
aged persons in whom ossification of the costal cartilages has taken 
place. 

The lateral anterior intercostal depressions at the lower part of 
the chest, are generally deeply marked with the act of inspiration in 
proportion to the exaggerated diaphragmatic effort ; and at the 
summit of the chest, the spaces above and below the clavicles are not 
infrequently depressed with this act. 

The foregoing account of the aberrations of motion have reference, 
for the most part, to the appearances manifested on both sides of the 
chest in cases in which both lungs are affected to a considerable 
extent. If the disease be limited to one lung, the dyspnoea is not 
sufficient to give rise to the general effects just described. On com- 
parison of the two sides, under these circumstances, a marked dis- 
parity will be observed as regards permanent expansion, reduced 
range of motion with the successive acts of respiration, etc. Cases 
in which the emphysema is limited to one side are rare ; but, as has 
been seen, when both lungs are affected, it is seldom that there does 
not exist an inequality in the amount of the affection in the two 
sides. The effects on the respiratory movements, as well as on the 
size and form, will then be more marked on the side which is most 
affected, the disparity as regards the signs furnished by inspection 
corresponding to the differences developed by a comparison of the 
results of percussion and auscultation. 

Mensuration affords a means of verifying the abnormal changes 
in size and the aberrations of motion, which are determined suffi- 
ciently for diagnosis by inspection. To state the results furnished 
by this method would be, for the most part, to repeat what has just 
been presented. 

Palpation furnishes some signs of importance. The alterations in 



452 DISEASES OF THE RESPIRATORY ORGANS. 

shape, the condition of the intercostal spaces, the mobility of portions 
of the chest, the direction of the ribs, and their moyements relatively 
to each other, are points which are ascertained by the touch as well 
as and in some respects better than by the eye. The sense of resis- 
tance, of which a judgment is formed incidentally while practising 
percussion, may be made a separate object of examination, audit then 
falls under the head of palpation. As respects the vibratory thrill 
communicated to the thoracic walls by the voice, and felt by the hand 
applied to the chest, in other words the vocal fremitus, it is found 
to vary in different cases, being in some instances increased, oftener 
diminished, and in other instances remaining unaffected. There is 
no constancy of relation between this sign and the affection ; hence, 
in its bearing on the diagnosis, it is unimportant. 

Examination with the hand is important in order to ascertain the 
situation of the heart. The absence of the cardiac impulse in the 
praecordia, shows this organ to be removed from contact with the 
thoracic walls. When it is depressed to the neighborhood of the 
epigastrium, its pulsations may be felt to the left of the ensiform 
cartilage. The impulse is not infrequently transferred to this situa- 
tion. 

Diagnosis. — The physical phenomena incident to vesicular emphy- 
sema, as already remarked, are highly distinctive of the affection. 
"With an adequate knowledge of these phenomena the diagnosis is 
sufficiently easy and positive. Without the advantage which this 
knowledge affords, the symptoms might be supposed to denote some 
other disease of which dyspnoea is a prominent feature, for example, 
disease of the heart, aortic aneurism, chronic pleurisy, pneumo-hydro- 
thorax, capillary bronchitis, pneumonitis, and acute phthisis. It will 
suffice to mention the more important points involved in the diffe- 
rential diagnosis from the several affections just named. 

From heart disease emphysema is distinguished by the absence of 
the physical signs of the former, except it has become developed as a 
complication. If the complication have occurred, the previous his- 
tory, in general, affords evidence of disturbance of the respiration 
for a long period prior to palpitations, or other symptoms of cardiac 
distujbance. With or without the conjunction of the symptoms and 
signs of disease of heart, the existence of emphysema is evidenced by 
the combined physical phenomena distinctive of the affection, which 
have been fully considered. 



VESICULAR EMPHYSEMA. 453 

• Aneurism of the aorta may cause a partial enlargement of the 
chest from the pressure of the tumor. But over the enlargement the 
percussion sound will be dull or flat, in place of the increased sonor- 
ousness due to rarefied lung. The positive signs of emphysema will 
be wanting, while, on the other hand, an aneurismal tumor has its 
positive signs, viz., pulsation, thrill, and a bellows' sound, synchronous 
with the heart's action. 

I have known the affection to be mistaken for chronic pleurisy. 
In this instance (to which reference has been already made) the 
dilatation was limited to the left side. This side on mensuration 
was found to be larger than the right, which was apparent on inspec- 
tion, and the intercostal depressions were effaced. Judged by these 
appearances, without the information furnished by percussion and 
auscultation, the existence of chronic pleurisy would be inferred, in 
view of the great infrequency of emphysema, to that extent, limited 
to one side. A vesiculo-tympanitic percussion-sound, extending to 
the base of the chest, in connection with feebleness of the respiratory 
murmur, and abnormal fulness above and below the clavicle on the 
left side, were the positive signs of emphysema ; the absence of flat- 
ness, or at least absence of vesicular resonance, excluding pleurisy 
with an amount of liquid effusion sufficient to produce obvious dilata- 
tion. 

So far as physical signs are concerned, the affection to which em- 
physema bears the nearest resemblance is pneumo-hydrothorax. In 
pneumo-hydrothorax the presence of air in the pleural sac causes di- 
latation of the chest, abnormal sonorousness on percussion, and sup- 
pression of the vesicular murmur of respiration. But as regards the 
physical phenomena, circumstances distinguishing the two affections 
are sufficiently marked. In pneumo-hydrothorax the percussion-re- 
sonance is purely tympanitic, while in emphysema the vesicular quality 
of sound is diminished but not lost. The latter affection never ac- 
quires the extreme drum-like sonorousness which characterizes dilata- 
tion of the chest from air within the pleural sac. In pneumo-hydro- 
thorax the sonorousness extends to a certain distance from the summit 
of the chest, and below the point to which it extends, there exists 
flatness on percussion, owing to the presence of liquid. In emphy- 
sema, when the affection is limited to the superior portion of the lung, 
the percussion-resonance is clear at the lower part of the chest. 
Pneumo-hydrothorax is always confined to one side of the chest ; 
this is very rarely true of emphysema. Moreover, pneumo-hydro- 



454 



DISEASES OF THE RESPIRATORY ORGANS. 



thorax has its characteristic physical signs, which never occur in con- 
nection with emphysema, viz., amphoric respiration, metallic tinkling, 
splashing on succussion. In 49 of 50 cases, pneumo-hydrothorax 
occurs from perforation in the course of tuberculosis of the lungs, 
and the existence of the latter disease is shown by the pre-existing 
and coexisting signs and symptoms. 

Emphysema complicated with ordinary acute bronchitis, presents 
certain of the diagnostic features of bronchial inflammation seated in 
the minute tubes. In capillary bronchitis the percussion-sound may 
be exaggerated, and become vesiculo-tympanitic. The dyspnoea in 
both cases may be extreme. The one affection is attended with great 
danger, the other, however distressing the symptoms, is rarely dan- 
gerous. The symptoms and signs, taken in connection with the previ- 
ous history, suffice for the discrimination. Capillary bronchitis is 
accompanied by great acceleration of the pulse ; in emphysema with 
ordinary bronchitis the pulse is moderately if at all increased in fre- 
quency. In capillary bronchitis the sub-crepitant rale is diffused 
over the chest on both, sides, especially over the posterior surface ; 
in emphysema it is an occasional sign, and never so much diffused. 
Capillary bronchitis occurs especially in childhood. Emphysema, 
sufficient to give rise to great disturbance of the respiration in con- 
nection with ordinary bronchitis, is rarely observed in early life. In 
cases of emphysema, in which the symptoms are rendered severe by 
an intercurrent ordinary bronchitis, the previous history, in the vast 
majority of cases, shows clearly the existence for a long period of dila- 
tation of the cells, and in a large proportion of instances the patient 
is subject to attacks of asthma. These circumstances have an impor- 
tant bearing on the differential diagnosis, not only from capillary 
bronchitis, but other affections with which it may possibly be con- 
founded. 

From pneumonitis and acute phthisis (to which may be added dila- 
tation of the bronchia), the differential diagnosis is settled at once by 
the physical signs. In each of these affections there are present the 
physical phenomena denoting solidification of lung, viz., dulness on 
percussion, bronchial respiration, increased vocal resonance or bron- 
chophony, and exaggerated fremitus. These points of distinction 
are abundantly sufficient, irrespective of those pertaining to symptoms 
and pathological laws, which are also distinctive. 

In conclusion, the diagnosis of emphysema requires only an ac- 
quaintance with its symptoms, signs, and pathological laws. "With 



INTERLOBULAR EMPHYSEMA. 455 

this knowledge it is recognized without difficulty in cases in which 
the dilatation of the cells is sufficient to give rise to the characteristic 
phenomena of the affection. 



SUMMARY OF THE PHYSICAL SIGNS BELONGING TO VESICULAR 
EMPHYSEMA. 

Exaggerated sonorousness on percussion, with a few exceptions. 
The resonance vesiculo-tympanitic. Sense of resistance increased. 
Feebleness, and in some instances suppression of the respiratory 
murmur. Inspiratory sound shortened (deferred) ; expiration pro- 
longed, but the pitch of expiration not higher than that of inspira- 
tion. The bronchial rales denoting bronchitis, pulmonary catarrh, or 
spasm, often present, especially the dry rales, and usually more 
marked with expiration. The inspiratory movements quickened and 
shortened, and those of expiration prolonged. The chest generally 
or partially enlarged, more or less, within the limits of a full inspira- 
tion. The space above and below the clavicle occasionally bulging. 
The intercostal depressions sometimes effaced. Curvature of the dorsal 
portion of spine forward, if the disease be general and of long stand- 
ing. The whole chest, in cases in which the affection is sufficient in 
degree and extent to give rise to dyspnoea, elevated as one piece, in 
inspiration, with but slight expansion. The movements of the dia- 
phragm restrained. The beating of the heart not felt in the praecordia, 
but in some instances at the epigastrium. 



Interlobular Emphysema. 

In this form of emphysema air is extravasated into the areolar 
structure, uniting together the pulmonary lobules. The morbid con- 
dition is identical with emphysema seated beneath the external tegu- 
ment of the body. To the latter, indeed, it may give rise, the air 
following the roots of the lungs into the mediastinum, thence into the 
subcutaneous areolar tissue of the neck, and becoming more or less 
diffused. Interlobular emphysema is almost invariably traumatic, 
arising from rupture of the air-vesicles in consequence of violent re- 
spiratory efforts. It is an exceedingly rare affection. The anatomi- 
cal characters consist of enlargement of the interlobular septa, the 
increased size beinoj crreater toward the surface of the lunor, causing; 



456 



DISEASES OF THE RESPIRATORY ORGANS. 



them to assume a wedge-like shape ; and detachment of the pleura by 
the pressure of air beneath this membrane, producing air-bladders, 
variable in size and more or less numerous. These air-bladders some- 
times attain to a considerable magnitude. I have seen a globular tumor, 
thus formed, as large as an English walnut, and they have been ob- 
served still larger. In a case reported by Bouillaud, there existed a 
sac so large that it resembled the stomach. They are movable by 
pressure ; and if there are several they may be made to coalesce. 
Similar sacs are sometimes found beneath the surface, differing from 
those caused by coalescence of the air-vesicles in the fact that they 
are seated in the interlobular areolar structure. In some cases the 
surface of the lung is studded with numerous small elevations of the 
pleura, presenting an appearance compared by RoMtansky to that 
of froth. Close examination of sections of lung affected with inter- 
lobular emphysema, shows the air-vesicles to be unaffected, except by 
the pressure of the enlarged septa, and the cavities formed in the 
areolar tissue. * 

This form of emphysema occurs in children more frequently than 
in adults. It is oftener situated in the upper than in the lower lobes, 
and is most prone to occur along the anterior borders of the upper 
lobe. 

The symptoms will be those incident to defective hsematosis, this 
being proportionate to the extent to which the air-vesicles are com- 
pressed by the abnormal size of the interstitial areolar tissue, and 
to the mechanical obstacle to the expansion of the lungs from the 
presence of sub-pleural extravasation. Cases have been reported in 
which sudden death was attributed to the rapid escape of air from 
the cells into the areolar tissue. Rupture of the pleural air-bladders 
may take place, giving rise to pneumothorax, and collapse of the 
lung. Owing to the great infrequency of the affection, the histories of 
well-attested cases have not as yet accumulated sujfficiently to furnish 
data for its symptomatic characters ; or, at all events, an analysis of 
recorded cases is yet to be made. 

The remark just made with respect to symptoms, will apply equally 
to physical phenomena. Laennec attributed to this affection two 
signs, neither of which have been found by subsequent observation 
to possess the significance attached to them by the discoverer of aus- 
cultation. One of these is the indeterminate sign styled by Laennec 
the dry crepitant rale with large bubbles {rale crepitant sec a grosses 
hulles) ; and the other a friction sound (bruit de frottement). The 



INTERLOBULAR EMPHYSEMA. 457 

first of these two signs is so doubtful in its character, as well as in 
its relation to pathological conditions, that it is clinically unimpor- 
tant. The second may possibly be present in some cases of inter- 
lobular emphysema, but occurs in the vast proportion of instances in 
connection with inflammation of the pleura. The rarefaction of lung 
induced by the presence of air in the areolar structure must, of 
course, give rise (except the tension of the thoracic walls be very 
great) to exaggerated sonorousness on percussion ; and, also, to 
feebleness of the respiratory murmur in proportion as the air-vesicles 
are compressed and the expansion of the lung restrained. The effects 
of this variety of emphysema on the configuration and size of the 
chest, as well as on the respiratory movements, remain to be studied. 
The combination of the physical signs furnished by percussion and 
auscultation is, thus, the same as in the ordinary form of emphysema, 
viz., dilatation of the air-cells. The differential diagnosis from the 
latter, with our present knowledge of the subject, so far as the symp- 
toms and signs referable to the chest are concerned, would be imprac- 
ticable. Circumstances in some cases incidental to the affection, may 
enable the physician to make the discrimination clinically. If the 
physical signs and symptoms denoting rarefaction of lung are deve- 
loped suddenly, or with more or less rapidity, evidently proceeding 
from an injury occurring in connection with some unusual effort of 
the respiratory organs ; for example, after violent coughing, the 
straining of parturition, a strong mental emotion, etc., the proba- 
bility is that the emphysema is traumatic and interlobular. If sub- 
cutaneous emphysema of the neck occur under these circumstances, 
the diagnosis is rendered quite positive. External emphysema, how- 
ever, unless it occur in conjunction with the physical signs denoting 
rarefaction of lung, is not evidence of this morbid condition, for 
it may proceed from rupture of the trachea or bronchi exterior to 
the pulmonary organs. Happily, owing to the great infrequency of 
this variety of emphysema, the absence of traits sufficiently distinctive 
to warrant a positive diagnosis in all instances, is rarely the occasion 
of embarrassment in medical practice. 



CHAPTER Y. 

PULMONARY TUBERCULOSIS— BRONCHIAL PHTHISIS. 

The affection called pulmonary tuberculosis, phthisis pulmonalis, 
or pulmonary consumption, involves as the point of departure for a 
series of destructive processes, the deposit in the lungs of the hetero- 
morphous product, tubercle. The nature of this product, the precise 
situation at which it is first deposited, its varying characters, the 
metamorphoses which it undergoes, and the structural changes inci- 
dent to the progress of the disease, are subjects which could not be 
touched upon without risk of being led into details inconsistent with 
the limits, as well as the plan of this work. Presuming the reader 
to have a general acquaintance, at least, with the morbid anatomy of 
the disease, I shall simply enumerate the abnormal conditions which 
stand in immediate relation to the phenomena furnished by physical 
exploration. The presence of tubercle causes, in proportion to its 
quantity, an increased density of the affected lung. Existing in the 
form of small isolated deposits, more or less numerous, the intervening 
pulmonary parenchyma being healthy, it constitutes a form of miliary 
and disseminated tubercles. The increased density due to the pre- 
sence of tubercles, either discrete or distributed in small clusters, may 
be but slight, but will, of course, correspond to their abundance and 
approximation to each other. Obstruction to the entrance of air 
into the cells, from the pressure of the tubercles on the small bronchial 
tubes, may not only abridge the respiratory processes in the part or 
parts affected, but cause a reduction in volume by collapse, more or 
less, of the cells not filled with tuberculous matter, and thus the density 
is still farther increased by condensation. The physical conditions 
represented by certain signs under these circumstances generally fall 
short of those incident to a more abundant exudation, when the de- 
posits no longer remain isolated, but enlarging by constant accretion, 
they at length coalesce and form continuous solid masses, frequently 
attaining to a considerable size. The latter constitutes more emphati- 



PULMONARY TUBERCULOSIS. 459 

callj tuberculous solidification, and a corresponding difference per- 
tains to the representative physical signs. So, also, if the tubercles 
be disseminated, and the intervening parenchyma become consolidated 
by inflammatory exudation, or infiltration of tuberculous matter 
(which not infrequently occurs), the physical conditions are the same, 
a continuous solidification in this case equally existing. 

The occurrence of circumscribed inflammation of the pulmonary 
parenchyma surrounding tuberculous deposits, preceding inflamma- 
tory exudation and solidification, may give rise to the auscultatory 
sign pathognomonic of pneumonitis, viz., the crepitant rale, and 
taken in connection with certain circumstances, as will be seen, this 
sign is evidence of tuberculous disease. 

The processes of softening, ulceration, and evacuation of the liquefied 
tuberculous matter, leaving pulmonary excavations, give rise to 
anatomical conditions quite different from those which pertain to the 
presence of crude tubercle, and these new conditions are represented 
by peculiar signs. But whereas, the fresh deposition of tubercle is 
usually going on while cavities are forming, and after they have 
formed, tuberculous solidification generally surrounds the excavations, 
and crude tubercles, in greater or less abundance, are distributed 
throughout the pulmonary parenchyma. Hence, the physical signs 
of different stages of the progress of tuberculous disease, viz., solidifi- 
cation and excavation, are likely to be conjoined. The size of exca- 
vations, their situation, their number, and even the firmness of their 
walls, as well as the varying contingent conditions relating to their 
contents, are found to affect the physical phenomena to which they 
give rise. 

The bronchial tubes in proximity to tuberculous deposits and exca- 
vations, are the source of physical signs. Circumscribed bronchitis, 
as will be seen, is evidence of the existence of tuberculosis. The 
presence of liquid in the tubes, either produced by bronchitis or 
derived from cavities, and the perviousness of the bronchise, constitute 
important physical conditions. 

The loss of expansibility of lung solidified by tubercle, and the 
reduction in its volume which frequently ensues from collapse and 
destruction of pulmonary tissue, furnish conditions which are repre- 
sented by physical signs. 

The attacks of circumscribed dry pleuritis which occur from time 
to time almost uniformly over tuberculous portions of lung, may also 
give rise to phenomena which become, inferentially, evidence of tuber- 
culosis. 



460 DISEASES OE THE RESPIRATOET 0EGAX5. 

Abnormal dilatation of air-cells, or emphysema, affecting more or 
less of the lobules in the vicinity of tuberculons deposits, is another 
morbid condition incidental to the disease in a certain proportion of 
cases, modifying the physical phenomena, and is not therefore to be 
lost sight of in clinical investigations. 

Systematic writers generally divide tuberculous disease of the lung 
into three stages, viz. : 1. Stage of crude tubercle ; 2. Stage of 
softening ; 3. Stage of excavation. With reference to the study of 
physical signs and their application to diagnosis, a more convenient 
division, as it seems to me, is the following : (a.) Small, disseminated 
tuberculous deposits ; (5.) Abundant deposition, involving considera- 
ble solidification ; (c.) Tuberculous disease advanced to the formation 
of cavities.^ I shall consider the physical signs and the diagnosis 
with reference to these three forms and periods of the disease. 

The following laws of pulmonary tuberculosis will frequently be re- 
ferred to. The deposit in the vast majority of cases takes place first at 
or near the apex of the lung. Exceptions to this law are occasionally 
observed. The deposit takes place at the summit of the lung on one 
side before the other lung is attacked ; but the opposite lung is subse- 
quently affected in the vast majority of instances. Hence, in the bodies 
of persons who have died with tuberculosis, the two lungs almost inva- 
riably are found to be diseased, but the deposit is most abundant or 
the ravages are more extensive on one side. These laws are of funda- 
mental importance in diagnosis. 

The claims of pulmonary tuberculosis on the attention of the medi- 
cal student and practitioner are sufficiently obvious in view of its 
great prevalence and mortality in all countries. But the study of 
its diagnosis is rendered immensely important by the fact that the 
prospect of exerting a control over the disease, and diminishing its 
tendency to a fatal issue, is in proportion to its early recognition. 

Pulmonary tuberculosis, as the rule, is essentially a chronic affec- 
tion. The chronic form is understood by the simple expression pul- 
monary tuberculosis. Occasionally, however, the rapidity of its 
career and the intensity of its symptoms denote an acute affection. 
Acute phthisis, I shall notice briefly under a distinct head. This 
chapter will also embrace a few remarks on the retrospective diag- 

1 To consider a stage oi'" softening, as distinct from the stage of excavation, mav be cor- 
rect as regards the morbid anatomy of the disease, but clinically it seems to me to be a 
needless division. The physical signs supposed to indicate such a stage are of doubtful 
significance. Hence, it will be observed that I do not undertake to point out means 
by which it may be recognized. 



PULMONARY TUBERCULOSIS. 461 

nosis of pulmonary tuberculosis, and on tlie diagnosis of bronchial 
phthisis. 

Physical Signs. — The clinical history of pulmonary tuberculosis 
embraces signs furnished by all the different methods of physical 
exploration. 

The phenomena developed by percussion are highly important. 
They are by no means altogether uniform at different periods of the 
disease, nor in different cases at the same period, varying with the 
various anatomical conditions just enumerated, and also affected by 
circumstances not included in that enumeration. 

Diminution of the normal vesicular resonance is a constant result 
of a tuberculous deposit, sufficient in amount to give rise to other 
signs, or to marked pulmonary symptoms. The varieties of percus- 
sion-signs consist of abnormal modifications of sound superadded to 
deficiency of vesicular resonance. Simple dulness, slight or moderate 
in degree and more or less extensive, at the summit on one side, 
compared with the resonance on the other side, is the evidence com- 
monly afforded, by percussion, of the existence of small disseminated 
collections of tubercle. To determine the fact of slight or moderate 
relative dulness, percussion is to be practised alternately at correspond- 
ing points on the two sides, observing all the precautions which have 
been pointed out in the chapter on percussion in the first part of this 
work. These precautions are essential if we would avoid errors. The 
symmetrical conformation of the two sides of the chest is to be ascer- 
tained. Slight or moderate dulness, on one side, ceases to be a morbid 
sign if, from spinal curvature, antecedent pleurisy, or other causes, 
this symmetry be disturbed. The natural disparity between the two 
sides at the summit which is habitual in many persons, must also be 
taken into account. It is to be borne in mind that, as a rule, in the 
majority of healthy persons with well-formed chests, the percussion- 
sound in the left infra-clavicular region has more sonorousness, more 
of the vesicular quality, and is lower in pitch, than in the corresponding 
region on the right side. Hence, distinct dulness, however slight, on 
the left side, is highly significant, while on the right side, if slight or 
moderate, it is to be taken as a morbid sign with considerable reserve. 
Distinct dulness at the left summit, be it ever so slight, in connection 
with the diagnostic symptoms of tuberculosis, may almost suffice to 
establish the fact of the existence of the disease, when, if situated on 
the right side, other corroborative evidence is requisite. 



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I PULMONARY TUBERCULOSIS. 463 

of small tuberculous deposit, some idea may be formed by the follow- 
ing analytical results. Out of 100 examinations in different cases of 
tuberculosis, in 22, from the aggregate of physical signs, the quantity 
of tubercle was presumed to be small. In each of these 22 examina- 
tions, dulness at the summit was distinct, being either slight or 
moderate in degree. In 14 cases the fact of dulness at the summit 
is simply recorded ; in 9 cases the particular situations of the dulness 
are specified. Of the latter 9 cases, the dulness existed in the post- 
clavicular region in 7, in the clavicular region in 6, in the infra- 
clavicular region in 6, and over the scapula in 9. Of the 22 cases, in 
10 the evidences of the deposit were manifested on the left, and in 12 
on the right side. These 100 cases, which will be repeatedly referred 
to, are taken in order from my clinical records, beginning with the 
last case recorded. The number, which might have been much larger, 
it is presumed is sufficient for the present objects of analysis. 

If the tuberculous deposit be abundant, the evidence of its presence 
afforded by percussion, in general, consists in a corresponding amount 
of dulness. The disparity at the summit of the chest is sufficiently 
obvious, requiring no unusual delicacy of manipulation or of the sense 
of hearing to elicit and discover it. The degree of diminution of the 
vesicular resonance is a measure of the completeness with which the 
lung is consolidated, and the area over which this resonance is found 
to be impaired or lost, is proportionate to the diffusion of the solidifi- 
cation. Dulness under these circumstances is not invariable. In 
complete and considerable solidification at the summit of the chest, 
the percussion-sound may be abnormally clear, the sonorousness even 
exceeding that of the opposite side. So far as my observations go, 
this anomaly occurs only on the left side, and in the few instances in 
which I have noted its occurrence, from the coexistence of marked 
gastric resonance at the inferior portion of the chest on that side, it 
is fair to conclude that in great part, at least, the sonorousness was 
transmitted from the stomach. However this may be, the sound is 
not a vesicular resonance ; it is tympanitic, i. e. devoid of the vesicu- 
lar quality, and elevated in pitch. With due attention to the quality 
and pitch of the sound, it need never be mistaken for a normal reso- 
nance, and the lesser sonorousness of the opposite side in consequence 
be attributed to disease. Other signs, moreover, will concur to pre- 
vent such an error. 

Without exceeding in sonorousness the resonance on the opposite 
side, the percussion-sound over tuberculous solidification may be more 



464 DISEASES OF THE KESPIEATOEY OEGAiv'S. 

or less clear and tympanitic. The sonorousness is diminislied, but 
the diminution of the vesicular quality of resonance is greater than 
the loss of clearness. To quote the happy expression employed by 
Dr. Stokes, there exists, under these circumstances, '-tympanitic dul- 
ness." The source of the tympanitic resonance, which thus, in a 
certain number of cases, rejDlaces the vesicular, in connection with 
tuberculous solidification, when not transmitted from the stomach or 
intestines, as stated in Part I, must be the air contained in the bron- 
chial tubes, or emphysematous dilatation of the air-cells, surrounding 
the solidified portion of lung ; or both may be combined. The occa- 
sional coexistence of emphysema affecting lobules in the vicinity of 
tuberculous deposits, is a fact belonging to the morbid anatomy of 
pulmonary tuberculosis, which was enumerated among the conditions 
modifying the physical signs. K the tuberculous deposit be abun- 
dant, but the solidification of lung not complete, then the vesicular 
resonance will not be wholly lost, but more or less diminished. And 
under these circumstances, the conditions giving rise to tympanitic 
resonance will cause a combination of diminished vesicular and of 
tympanitic resonance in various and varying proportions ; the sound, 
in other words, elicited by percussion will be vesiculo-tympanitic, the 
vesicular or the tympanitic quality predominating in different cases. 

Judging from my observations, I should say that in cases of abun- 
dant tuberculous deposit (of com-se not advanced to excavation), the 
diminution of the vesicular resonance is accompanied, as a rule, by 
more or less of tympanitic sonorousness, but the former, i. e. the 
dulness, is the more obvious element, and the latter, i. e. the tympa- 
nitic quality of sound, is overlooked if it be not unusually prominent, 
unless the attention be dii'ected particularly to it. On the other 
hand, in a small proportion of cases, the percussion-sound over tuber- 
culous solidification is dull almost to flatness. 

The tympanitic resonance due to transmitted gastric sonorousness 
on the left side, at the summit, may prevent dulness at the summit of 
the right side, dependent on an abundant deposit of tubercle, from 
being readily appreciated. I have noted an instance of this descrip- 
tion, the auscultatory phenomena showing the existence of a consi- 
derable quantity of tuberculous matter at the summit of the right 
lung. 

An abnormal sense of resistance is a valuable collateral means of 
determining the fact of tuberculous solidification, in the practice of 
percussion. Especially is this point important when there is found 



PULMONARY TUBERCULOSIS. 465 

to be only a moderate relative dulness on the right side, which we 
may not be altogether certain is not due to a natural disparity. An 
increased sense of resistance in concurrence with the dulness, confirms 
its morbid character. 

Irrespective of the quality of the resonance which remains, marked 
dulness on percussion, as already stated, over the site of an abundant 
tuberculous deposit, is the rule. Out of 100 examinations of diffe- 
rent cases of pulmonary tuberculosis, of which I have transcribed the 
recorded physical signs for the sake of reference in writing these 
remarks, excluding the cases in which the quantity of tuberculous 
deposit was small, and also the cases in which the evidences of exca- 
vation were ascertained, 6^ cases remain of more or less complete and 
extensive solidification depending upon abundant tubercle. In 35 of 
these cases the dulness is noted to have been marked, and in several 
instances the fact of dulness is alone stated without expressing its 
degree. In five instances the percussion-sound was almost flat. In 
three cases only was there greater sonorousness, tympanitic in quality, 
over the solidified lung, and in each of these instances the left side 
was the seat of the solidification, and gastric resonance was marked 
over the whole of the left side. With a single exception, whenever 
the different regions of the summit were specified, the diminished 
vesicular resonance was observed over, above, and below the clavicle 
in front, but frequently more marked over the scapula behind. In 
the single exceptional instance just referred to, a disparity was 
marked over the scapula and not in front. It was often sufficiently 
obvious that the resonance was diminished at the summit on both 
sides. The existence of marked relative dulness in front on one side, 
and an equally marked relative dulness over the scapula on the other 
side, is also noted. -^ 

When tuberculosis has advanced to the formation of cavities, the 
phenomena furnished by percussion vary, not only in different cases, 
but often in the same case at different examinations made during the 
same day, the latter variations depending on the state of the excava- 
tions as respects their liquid contents. More or less tuberculous 
solidification continues after cavities are formed ; and if, in addition, 
the cavities are filled with liquid, the physical conditions favorable to 
marked dulness or even flatness on percussion are eminently present. 
But if they are empty, and of considerable size, they may give rise 
to an abnormally clear and tympanitic percussion-sound, which 
occasionally presents other and more characteristic modifications of 

30 



466 DISEASES or the KE5PIRAT0RY ORGAXS. 

quality, viz., the amphoric and the cracked-metal varieties of tone. 
So far as percussion is concerned, the evidence of the existence of 
excavations consists in the signs just mentioned, viz., tympanitic reso- 
nance and the amphoric and cracked-metal modifications. How far 
are these phenomena available in determining the existence of exca- 
vations ? A tympanitic sonorousness, as we have seen, may replace 
the vesicular resonance over tuberculous solidification, and the tym- 
panitic sound, under these circumstances, may be quite intense at 
the summit of the left side. When incident to solidification, the 
tympanitic quality is considerably difi'used. On the other hand, if 
it be due to the presence of air in a cavity, it is circumscribed in 
proportion to the limited size of the excavation. This is a diff"erential 
point. Another point relates to the percussion-sound over the por- 
tions of the chest adjoining the space to which the tympanitic sonor- 
ousness is limited. Tuberculous excavations being usually surrounded 
by solidified lung, the limits of the circumscribed tympanitic sonor- 
ousness may be somewhat abruptly defined by a dulness which con- 
trasts strongly with the sound elicited over the cavity. It is possible 
in some instances, by careful percussion, to delineate on the chest, by 
means of this abrupt change from a clear to a dull sound, the site of 
an excavation. The alternate presence and absence of tympanitic 
sonorousness in the same situation at different examinations is a 
diagnostic point. By taking the necessary pains to practise percus- 
sion very early in the morning, before the contents of an excavation 
are expelled, and subsequently after an abundant expectoration, the 
change from marked dulness to clearness of resonance in a particular 
part of the chest may be ascertained, and thus shown to depend on 
the removal of morbid products, which, in view of other signs and 
symptoms, we cannot doubt came from a cavity. The modifications 
of tympanitic resonance called amphoric and cracked-metal, in them- 
selves are highly significant of a tuberculous cavity. Both may occur 
independently of excavation, as has been pointed out in Part I, but 
the instances are exceptional and rare. Inasmuch, however, as these 
modifications are only occasionally observed when cavities undoubt- 
edly exist, their absence is not evidence of the non-existence of exca- 
vation. They have a positive significance when present, but in a 
negative point of view are unimportant. 

In a considerable proportion of cases of tuberculosis advanced to 
excavation, percussion fails to develope any distinct evidence of the 
existence of cavities. This remark will be found presently to be 



PULMONAEY TUBERCULOSIS. 467 

also applicable to the other methods of exploration. The reason is, 
that in addition to the existence of excavations, various contingent 
circumstances must be combined, in order that the distinctive signs 
shall be produced. The circumstances favorable for the character-- 
istic percussion-signs, and at the same time most of the distinctive phe- 
nomena derived from other methods of exploration, have been already 
mentioned (Part I), but they may be repeated in this connection. 
The size of the cavity is important. It must have attained to a cer- 
tain magnitude, and, on the other hand, should not be too capacious. 
It must be empty, or at least only partially filled with liquid. Its 
situation relative to the superficies of the lung is important. The 
thinner and the more condensed the stratum of the lung separating 
the cavity from the thoracic wall, the greater the tympanitic sonor- 
ousness ; and it is a still more favorable circumstance if over the 
excavation the pleural surfaces have become firmly adherent. The 
incompleteness with which these circumstances are conjoined in many 
cases, and the occasional absence of the indispensable condition per- 
taining to the contents of the cavity, sufiiciently account for the in- 
frequency with which the existence of excavations is positively ascer- 
tained, especially at a single examination. 

Of the 100 examinations already referred to, in 13 the physical 
signs were considered to denote the existence of excavations. It is, 
however, more than probable that among the 65 cases of abundant 
tuberculous deposit, were many cases in which the disease had ad- 
vanced to the formation of cavities, the physical signs at the time of 
the recorded examination indicating only solidification. Of the 13 
cases, in 6 circumscribed tympanitic sonorousness existed, which was 
attributed to empty excavations. In some of these cases the exis- 
tence of cavities was subsequently verified by autopsical examinations. 
In 4 cases the amphoric modification, and in 2 the cracked-metal 
intonation was noted. 

In leaving the subject of the percussion-signs belonging to tubercu- 
losis, two or three rules, with respect to the practice of percussion 
may be mentioned, which are to be borne in mind, particularly in 
cases in which the tuberculous deposit, if it exist, be small. The 
importance of observing the general precautions pointed out in the 
chapter on percussion in Part I, has been already adverted to. In 
cases of doubt, it is useful to compare the chest as regards the results 
of superficial and deep percussion alternately. Slightly increased 
density near the surface of the lung on one side may give rise to 
dulness on light percussion, when with forcible strokes the disparity 



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PULMONARY TUBERCULOSIS. 469 

sated for, and a disparity in the percussion-sound is not obvious. 
This may be true occasionally, as regards mere sonorousness, or the 
degree of resonance ; but under the circumstances just mentioned, the 
quality and pitch of sound can hardly fail to undergo an appreciable 
alteration : the resonance, although not less clear than on the opposite 
side, becomes vesiculo-tympanitic and raised in pitch. The impor- 
tance of analytically resolving the sound elicited by percussion over 
the chest into its different elements, and studying the abnormal 
modifications which these elements may respectively undergo, is 
illustrated in the instance just cited. 

The auscultatory phenomena belonging to the clinical history of 
pulmonary tuberculosis, embrace the greater part, if not, indeed, 
the whole of the catalogue of the physical signs furnished by this 
method of exploration. In their relation to the disease the follow- 
ing distinction may be made : the adventitious sounds, viz., the rales 
and friction-sounds, are contingent or accidental phenomena, occa- 
sionally present, and although possessing, when present, diagnostic 
significance, their absence does not constitute any ground for inferring 
the non-existence of the disease. On the other hand, the signs which 
are included in the class of modified respiratory sounds, are more 
intimately and constantly connected with the morbid conditions inci- 
dent to the disease. They are therefore more important as diag- 
nostic criteria, and they are important in a negative point of view. 
If the respiratory sounds are free from any abnormal modification, 
a tuberculous deposit can hardly exist. The fact enables us to ex- 
clude the disease. 

In cases of small, disseminated tuberculous deposits, so far as the 
phenomena consist of modified respiratory sounds, they will mostly 
come under the head of broncho-vesicular respiration. In the sense 
in which I have used this term, it embraces all the elements of the 
bronchial respiration, except that the inspiratory sound is not wholly 
tubular, but presents the tubular and vesicular qualities combined. 
It is the rude respiration of writers on the subject of physical explo- 
ration, sometimes also styled harsh and dry respiration. If all the 
characters of the broncho-vesicular respiration are present, we shall 
have an inspiratory sound neither purely tubular nor vesicular in qua- 
lity, but a mixture of both (broncho-vesicular), the duration somewhat 
shortened (unfinished), the pitch raised; a brief interval, followed by 
an expiratory sound, prolonged, frequently longer and more intense, 
than the inspiration, and higher in pitch. Sometimes in connection 



470 DISEASES OF THE EESPIRATOET ORGANS. 

witli a small amount of tulDerculous disease all these characters are 
observed, but oftener more or less of them are wanting. The pre- 
sence of certain of the broncho-vesicular elements, and the absence 
of others, give rise to considerable diversity in different cases. These 
diversities it will be useful to study vrith a little detail. It is need- 
less to remark that in determining the existence and the characters 
of abnormal modifications of the respiration, auscultation is to be 
practised at the summit of the chest on both sides, and the pheno- 
mena carefully compared. On the side affected, the intensity of the 
respiratory sound may be either increased or diminished. It is much 
oftener diminished,^ but when it is not too feeble to be distinctly 
heard, if the lessened intensity be due to increased density of lung, pro- 
duced by tuberculous disease, it is always altered in other particulars ; 
in other words, more or less of the broncho-vesicular characters are 
added, these characters being independent of the intensity of the 
sound. The fact just stated will serve to distinguish the feeble respi- 
ration due to tuberculous disease from that incident to simple emphy- 
sema. Occasionally the inspiratory sound is inappreciable, unless 
Cammann's stethoscope be employed. On the other hand, the inspi- 
ratory sound may be alone heard, i. e. without any sound of expira- 
tion. The abnormal modifications will then consist of shortened 
duration, diminished vesicular or acquired tubularity of quality, and 
elevation of pitch, pertaining, of course, exclusively to the inspira- 
tion. These three characters go together. The variation in pitch 
is frequently the character most readily recognized. Miideiiess, 
Jiarshiess^ and dri/ness of the sound, pertain to this character to- 
gether with the tubularity. These three characters are shown by 
contrast with the longer duration, the more marked vesicular quality, 
and the comparative lowness of pitch, which belong to the inspiratory 
sound on the opposite side, or over the middle and lower third of the 
chest on the same side. If an expiratory sound be present, it is 
often, if not generally, more intense than the sound of inspiration. 
Its intensity, however, varies. More or less prolonged, its duration 
differs in different cases. It is uniformly higher in pitch than the 
inspu*atory sound, the disparity being in some cases much more 
marked than in others. A point of contrast between the two sides 
of the chest in some instances is the presence of an expiratory sound 

"" Fournet states that increased intensity of the respiratory sound is the first change 
induced by the deposit of tubercle (op. cit). My observations lead me to an opposite 
conclusion, as stated above. 



i 



PULMONARY TUBERCULOSIS. 47l 

on one side and not on the other ; and if diffused over both sides, its 
characters are the reverse of those which render it a sign of increased 
density of lung from tuberculous disease; they are relative shortness 
of duration, with less intensity and pitch lower than belong to the 
sound of inspiration. As the expiratory sound is sometimes wanting, 
so in some instances it is alone present, no sound of inspiration being 
discoverable. It is not uncommon in cases of tuberculosis to find 
the following results on comparing the two sides of the chest: on 
one side a vesicular inspiration, more or less intense, with no expira- 
tory sound, and on the opposite side a prolonged, more or less intense 
and acute expiration, with a very feeble or scarcely appreciable sound 
of inspiration. 

The diversities which different cases present as respects the pre- 
sence or absence of more or less of the elementary characters of the 
broncho-vesicular respiration, are not of importance from their pos- 
sessing respectively any special significance. The simple point 
practically is to determine the existence of any of the elements of 
the broncho-vesicular respiration. The broncho-vesicular respiration, 
in conjunction with other signs and with symptoms, is diagnostic of a 
tuberculous deposit not producing complete solidification, extending 
over a considerable space, at or near the apex of the lung. Its 
availability in diagnosis of course depends on its constancy, and the 
facility with which it may be recognized. Guided by the impressions 
derived from my own experience, I should say that cases belonging in 
the class of small, disseminated tuberculous deposits, are extremely 
rare in which certain of its elements are not sufficiently marked to 
be appreciated by one acquainted with the subject, and possessing a 
fair amount of skill as a practical auscultator. 

In comparing the respiratory sounds at the summit of the chest, 
in front and behind, on the two sides, it is essential, if we would avoid 
errors, to make due allowance for the points of normal disparity exist- 
ing in many persons in this part of the chest. These have been con- 
sidered in the chapter on auscultation, in the first part of this work, 
to which, in the present connection, the reader is referred. It is to 
be borne in mind, that on the right side, at the summit, especially in 
front, the inspiratory sound is frequently less intense, less vesicular, 
and higher in pitch, than on the left side, and that a prolonged expi- 
ration on the right side, occasionally more intense and higher in 
pitch than the inspiratory sound, and sometimes existing alone, is 
observed in healthy persons. Hence, the character of the broncho- 



472 DISEASES OF THE EESPIRATORT ORGANS. 

vesicular respii-ation should be strongly marked at tlie summit of the 
right side, for it to be considered, in itself, as evidence of disease ; 
but, on the other hand, if situated at the summit of the left side, it 
is much more significant of a morbid condition. 

Until the deposit of tuberculous matter becomes abundant, the 
broncho-vesicular modification of the respiration, in the greater pro- 
portion of instances, is limited to one side of the chest. This fact 
obtains in cases in which there is every reason to suppose that both 
lungs contain tubercles. In view of the fact that after a tuberculous 
deposit has taken place in one lung, in a short time the other lung 
becomes affected, I have often been surprised at finding the respira- 
tion over the lung least affected nearly or quite normal. It is true 
that under these circumstances we have not a healthv lunoj to serve 
as a standard of comparison, but without such a comparison, it is 
practicable to judge of the pitch and vesicular quality of the inspira- 
tion, and the relative intensity, duration, and pitch of the expiration, 
if the latter be present, and thus to determine whether the respira- 
tion be broncho-vesicular or not. I can only account for the fact 
now referred to, by supposing that when the increased density at the 
summit of one lung is sufficient to occasion a distinct modification of 
the respiratory sound, the activity of the other lung is sufficiently 
increased for the normal characters to be maintained, notwithstand- 
ing the presence of a certain number of tubercles, without giving 
rise necessarily to a well-marked exaggerated respiration. A well- 
marked exaggerated respiration, as will be presently noticed, does 
occur in the opposite lung in some instances, in which the amount of 
tuberculous deposit is considerable on one side. 

Interrupted, wavy, or jerking respiration, is a modification occur- 
ring in a certain proportion of cases of small tuberculous deposit, 
but also observed occasionally when other signs and the symptoms 
do not denote tuberculous disease. Its value as a diagnostic sign, 
therefore, depends on its being associated with other evidence of 
tuberculosis. In the 22 examinations in cases of small, disseminated 
tubercles, among the 100 analyzed, this sign was observed in two. 

Of adventitious sounds or rales, the crepitant, dry crackling, crump- 
ling, the sub-crepitant, and the other bronchial rales, moist and dry, 
particularly the latter, are all occasionally observed in cases of tuber- 
culosis. They do not indicate the disease directly, but, on the con- 
trary, if we except dry crackling and crumpling, they are the signs 
generally of other morbid conditions. Indii'ectly, they become signi- 



PULMONARY TUBERCULOSIS. 473 

ficant of a tuberculous affection when they occur under circumstances 
which warrant the inference that the particular morbid conditions 
which they immediately represent involve the coexistence of tuber- 
cles. Their relation to the disease, as already remarked, is therefore 
contingent or accidental. 

A veritable, well-defined crepitant rale denotes pneumonitis in the 
vast majority of cases. Pneumonitis, occurring between the extremes 
of life, if it be circumscribed, i. e. extending over a portion only of 
a lobe, and situated at or near the apex of the lung, is highly signifi- 
cant of tuberculosis, because, in the first place, under these circum- 
stances it is not primary, since primary pneumonitis extends over a 
whole lobe, and affects by preference the inferior lobe ; and, in the 
second place, observations show that circumscribed pneumonitis is 
occasionally developed in the vicinity of tuberculous deposits, viz., at 
or near the apex of the lung. A crepitant rale is thus inferentially 
a diagnostic sign of tuberculosis when it is found at the summit of 
the chest, extending over a limited area. As respects the frequency 
of the occurrence of circumscribed pneumonitis, in connection with 
tuberculous disease, and the consequent frequency with which a cre- 
pitant rale well-marked (in distinction from dry crackling) becomes a 
sign of the latter affection, my experience accords with that of Dr. 
Walshe, viz., the coincidence is rare. It is not, however, less signi- 
ficant on this account when it does take place. 

Dry crackling, as distinguished from a well-marked crepitant rale, 
consists of a few crepitations, apparently reaching the ear from a 
distance, generally confined to the end of the inspiratory act. What- 
ever opinion may be entertained of the mechanism of its production, 
observations show that it frequently occurs in the early stage of 
tuberculosis, and is rarely observed, at the summit of the chest, 
except there exist a tuberculous affection. Hence it possesses a cer- 
tain degree of significance, especially when associated with other 
signs and with symptoms having a similar diagnostic bearing. Of 
the 22 examinations in cases presumed to be of small disseminated 
tubercles, it was noted in 9. In several instances it existed at the 
summit of the chest on both sides, but was more marked on the side 
which the associated signs indicated as the seat of the deposit. 

The same remarks are applicable to a crumpling sound, except 
that the latter is much less frequently observed in cases of tubercu- 
losis. For all practical purposes it suffices to consider this as a 
variety of crackling. 



474 DISEASES OF THE EESPIRATORY ORaANS. 

A sub-crepitant rale is occasionally developed in proximity to 
tubercles, proceeding either from the presence of liquid matter es- 
caping from the cells into the smaller bronchial tubes, or produced 
within the tubes as the result of circumscribed capillary bronchitis. In 
either case its situation at the summit of the chest, and the limited 
space in which it is heard, are the conditions under which it is signi- 
ficant of tuberculosis. 

The occasional development of bronchitis, not only in the smaller 
but the larger tubes in the vicinity of tubercles, is an event belong- 
ing to the natural history of pulmonary tuberculosis. Hence, the 
production of sibilant, sonorous, and mucous rales. These rales re- 
present morbid conditions pertaining to bronchitis ; but bronchitis 
limited to the upper portion of the lungs, and especially confined to 
one side, is not a primary afi'ection. These restrictions conflict with 
the laws of primary bronchitis, which is one of the symmetrical dis- 
eases, and extends over the bronchial tubes distributed to the lower 
as well as the upper lobes. The physical signs of primary bronchitis, 
as has been seen, are especially manifested, not in front at the sum- 
mit, but over the middle and lower portions of the chest behind. Hence, 
when confined to the summit, and especially to one side, the bron- 
chitis is secondary, and in this situation the probabilities are greatly 
in favor of its being induced by tuberculous disease.^ 

Moist crackling or mucous rales may, however, be produced by 
the escape of softened tuberculous matter into the tubes without 
necessarily involving the coexistence of circumscribed bronchitis. 
The development of moist or bubbling sounds is generally regarded 
as a circumstance distinctive of the fact that softening has taken 
place. Undue significance, as it seems to me, has been attached to 
this circumstance. It is impossible to determine from the characters 
of the sounds whether they proceed from the presence of softened 
tuberculous matter, or from mucous secretions, or (as must be the 
case frequently) from both combined. And inasmuch as circum- 
scribed bronchitis may undoubtedly exist before softening of the 
tuberculous matter ensues, mucous rales are heard before the disease 
has advanced to this stage. Not indicating necessarily softening, 
m'oist rales limited to the summit of the chest are highly diagnostic of 

' A clicldng sound has been supposed to be specially significant of the existence of 
tubercles. It is so, however, solely for the reasons which invest other bronchial rales 
with this significance. There are no grounds for regarding the character of the sound 
as distinctive. A clicking sound is heard in primary as well as secondary bronchitis. 



PULMONARY TUBERCULOSIS. 475 

tuberculosis, and in cases of doubt it is useful to auscultate repeatedly, 
and especially in the morning before expectoration has taken place, 
in order to discover them, if they exist. 

It thus appears that with respect to all the adventitious sounds or 
rales just noticed, their diagnostic value in cases of tuberculosis 
depends on their being limited to a circumscribed space at the summit 
of the chest. Their value is enhanced by association with other 
phenomena, physical and vital, pointing to tuberculous disease. 
They are occasionally, not constantly, present in cases of tuberculosis. 
They cannot, therefore, be relied upon in the diagnosis ; and, as 
already remarked, although of importance when present, we cannot 
argue against the existence of tuberculous disease from their absence. 
As criteria of the disease, they are much less important than the 
phenomena included under the title of the broncho-vesicular respira- 
tion. 

An abnormal transmission of the heart-sounds, oftener observed 
and more marked in cases of abundant tuberculous deposits, may be a 
sign of some value when the affection consists of small disseminated 
tubercles. If the sounds of the heart are heard with equal, if not^ 
greater distinctness, at the summit of the right as of the left side, it 
is a point the more worthy of attention from the difficulty of deter- 
mining, in some instances, whether the characters of the broncho- 
vesicular respiration on the right side are due to a morbid source, 
or merely to a natural disparity. This difficulty, which is an 
obstacle in the way of the diagnosis when the tuberculous affection 
is seated in the right lung, renders the collateral evidence of the 
disease in this situation of greater practical value than when the left 
lung is affected. It is chiefly with reference to the detection of 
tuberculosis on the right side that this sign is useful ; and, obviously, 
it is a sign more available on the right, than on the left side. 

Passing next to the auscultatory phenomena produced by the 
voice, an exaggerated vocal resonance is an important physical sign 
of tuberculosis when it exists at the summit of the chest on the left 
side. On the other hand, a relatively greater degree of resonance 
on the right side, in itself, has little or no diagnostic importance. 
This difference is owing to the normal disparity found in most persons, 
especially in front. The greater intensity of vocal resonance on the 
right side natural to many persons, is such that it is not safe to pro- 
nounce positively any amount, within the limits which small dissemi- 
nated tubercles are competent to produce, to be morbid when it is 



476 DISEASES OF THE EE5PIRAT0RT OR a AN 3. 

observed on tliis side. If, liowever, a greatly exaggerated resonance 
on the right side is found in conjunction with other signs existing on 
this side which point to tuberculosis, it derives some weight from the 
association. The fact of the disparity between the two sides so often 
existing in health, renders an exaggerated resonance on the left side 
doubly significant. It is entitled to great weight in the diagnosis. 
It is frequently the case, however, that notwithstanding a tubercu- 
lous deposit in the left lung, the vocal resonance continues greater 
on the right side. The fact, therefore, that the resonance is not 
exaggerated on the left side does not militate against the existence of 
tuberculous disease on that side. 

A bronchial souffle or puff accompanying whispered words is to be 
included among the vocal phenomena indicating increased density of 
lung from tuberculous deposit. A bellow's-sound, more or less intense 
and high in pitch, existing within a limited space of the summit of 
the chest on one side, and especially on the left side, is a valuable 
sign in the diagnosis of tuberculosis. Analogous in its character 
and mechanism to the high-pitched intense expiratory sound in the 
bronchial and the broncho-vesicular respiration, it may be developed 
in cases in which the signs just mentioned are obscure or even absent. 
This sign is presented in a more marked degree in connection with 
an abundant tuberculous deposit, but in cases of small disseminated 
tubercles a souffle may be discovered on the affected side when it is 
absent on the opposite side, or, if present on both sides, the greater 
intensity and the elevation of pitch on one side constitute the morbid 
characters. It is a more significant sign if it exist on the left side, 
because it is found in some persons more developed and acute on the 
right side as a normal disparity. 

Directing attention now to the phenomena furnished by auscultation 
when the tuberculous deposit is abundant, and the lung near its apex 
to a greater or less extent solidified, the respiratory sound may pre- 
sent still the broncho-vesicular modification, more marked than 
before, or more or less of the elements of the bronchial respiration 
may be strongly marked, or the respiratory sound may be sup- 
pressed. 

Suppression of the respiratory sound over tuberculous solidification, 
is rarely observed at the summit of the chest in front. It occurs 
oftener, but by no means frequently, over the scapula. It' is noted 
in but 5 of 62 examinations. Diminished intensity of the respiratory 
sound, however, is a frequent modification. It occurs much oftener 



PULMONARY TUBEEC UL SIS. 477 

than an increase of the intensity. Of 38 examinations in different 
cases in which the facts pertaining to this point were noted, the 
number of instances in which there was diminution on the side most 
affected is 26, while the intensity was greater than on the opposite 
side in 12. The diminution in different cases varies much in degree. 
In several instances among the cases just referred to, the sound was 
so feeble as to be scarcely appreciable, and it was difficult to study 
its characters aside from the intensity. The characters, under these 
circumstances, are those which belong either to the broncho-vesicular 
or to the bronchial respiration. Occasionally tuberculous solidifica- 
tion gives rise to a bronchial respiration, with all its characters as 
intense as in the cases of pneumonitis in which it is most strongly 
marked, — the inspiration loud, tubular, high in pitch, followed, after 
a brief interval, by an expiratory sound, prolonged, higher in pitch, 
and more intense than the sound of expiration. Thus complete, it 
occurs in but a certain proportion of cases. Usually a portion only 
of the elements of the bronchial respiration are present. An inspi- 
ratory sound may alone be heard, which, if bronchial, is purely 
tubular, i. e. devoid of any vesicular quality. Less frequently an 
expiratory sound is alone heard, which is more or less prolonged, 
high in pitch, sometimes loud and near the ear ; in other instances 
faint and distant. These diversities, when the quantity of tubercu- 
lous deposit is abundant, as well as when it is small, do not denote 
any special pathological distinctions. The practical point is simply 
to determine the fact of the existence of more or less of the elements 
of the bronchial respiration. With an equal amount of disease, 
owing to differences in the disposition of the tuberculous matter, the 
bronchial respiration in one case may be intense and complete, and 
in another case comparatively feeble and imperfect. The most 
strongly marked bronchial respiration may only show that the solidi- 
fication, in its relations to the larger bronchial tubes and the surface 
of the lung, is disposed in a manner most favorable for the develop- 
ment and transmission of the sound. 

In cases of considerable tuberculous solidification at the summit of 
one lung, a deposit more or less in amount exists at the same time in 
the other lung. Auscultation on the side opposite to that most 
affected, may discover the characters of the broncho-vesicular or the 
bronchial respiration more or less marked. An obvious disparity 
between the two sides is usually apparent ; but it is occasionally 
somewhat difficult, by the combined results of percussion and auscul- 



478 DISEASES OF THE RESPIRATORY ORGANS. 

tation, to determine on which side the disease is most advanced. 
This difficulty, however, very rarely exists if the disease has not 
advanced to excavation, and, under the latter circumstances, is not 
often experienced. On the other hand, while the lohysical evidence 
of extensive tuberculous solidification on one side exists in some 
instances, on the opposite side the vesicular murmur apparently 
retains its normal characters. In such cases the respiration on the 
side least affected is supplementarily exaggerated ; and this abnormal 
development of the vesicular mm-mur prevents those modifications 
from being manifested which would be observed with the same 
amount of disease, if the other lung were not affected. 

Adventitious sounds, or rales, are frequently heard in auscultating 
patients with abundant tuberculous deposit. Including friction-sounds, 
they are noted in 25 of 62 recorded examinations, made in different 
cases. The rales noted in these examinations are either the crepitant 
or sub-crepitant (the record, sometimes only stating crepitation) in 
6 ; dry crackling, in 3 ; sonorous, in 5 ; sibilant, in 6 ; a clicking 
sound in 3 ; a mucous or bubbling sound in 2. Interrupted respira- 
tion is also observed in a certain proportion of cases in which the 
quantity of tubercle is abundant. It is noted in 5 of 62 examina- 
tions. But in three of these five instances it was observed on rhe 
side opposite to that most affected, — a fact going to illustrate the rela- 
tion of this sign to a small, rather than an abundant, deposition of 
tubercle. The rales have the same significance as at a prior date, 
when the quantity of tubercle is small. The modified respiratory 
sounds, being more constant, are in a diagnostic point of view of 
much more importance. The latter becoming generally more marked 
as tuberculous solidification is induced, the rales are of less value 
than at an earlier period in the disease, when the deviations from the 
character of the normal respiration are not so apparent, and the 
diagnosis accordingly more difficult. 

A friction-sound may accompany a tuberculous deposit small in 
amount. Instances are referred to in the first part of this work in 
which this sign was due to the pulmonary pleural surface becoming 
roughened by the projection of numerous isolated miliary tubercles, 
deposited immediately beneath it. This is an accidental circumstance 
of very rare occurrence. When the sign occm'sitis significant, gene- 
rally, of circumscribed dry pleuritis over the tuberculous deposits. 
While the quantity of tuberculous matter is small, it is extremely 
rare for a friction-sound to be developed ; nor is it by any means a 



« 

PULMONARY TUBERCULOSIS. 479 

frequent sign of abundant tubercle. Although drcumscribed pleuritis 
is so constant an event in the history of tuberculosis, the superior 
costal movements probably do not involve sufficient attrition of the 
roughened surfaces to give rise to an appreciable sound ; and, more- 
over, adhesion doubtless speedily follows the fibrinous exudation. 
This sign was noted in 2 of 62 cases of abundant tuberculous deposit. 
In both these cases the patients were females, and it is probably true 
that a friction-sound at the summit of the chest is oftener met with in 
females, owing to the predominance in them of the superior costal type 
of respiration.^ 

In cases of tuberculous solidification on the right side, the sounds 
of the heart are found to be unduly audible in a large proportion of 
the cases in which the attention is directed to this point. Like the 
other contingent phenomena, however, this sign is of less importance 
than at an earlier period, when the physical evidence of the disease 
derived from percussion and the modified respiration is less clear and 
positive. 

An arterial bellow's-murmur, in the infra or post-clavicular region, is 
a physical sign occasionally observed, probably due to pressure of a 
mass of tubercle on the subclavian artery. This sign has not infre- 
quently attracted my attention. When present on one side, and not 
on the other, and especially on the side presenting other phenomena 
indicating tuberculous disease, it is to be included in the list of con- 
tingent signs which concur to confirm the diagnosis. If it exist on 
both sides it may be an anaemic murmur, or attributable to pressure 
of the stethoscope. As an isolated sign it is 'entitled to but little 
consideration. 

The vocal phenomena furnished by auscultation are more uniformly 
present and much more marked when considerable tuberculous solidi- 
fication exists, than in cases of small disseminated tubercles. If the 
right side be the seat of the more abundant deposit (which, so far as my 
observations go, is true of the larger proportion of cases), the vocal re- 
sonance is generally so disproportionately intense, compared with the 
left side, that there can be no question as to its not being due to the 
natural disparity existing between the two sides. On the left side the 
intrinsic evidence of its morbid character is, of course, still more con- 
clusive. But the rule as to an increased vocal resonance is by no means 

' A friction-sound at the summit of the chest, developed in the course of piUmonary 
tuberculosis, is always of the grazing variety; never rough or rasping, as at the lower 
part of the chest in some cases of general pleurisy. 



480 DISEASES OF THE RESPIRATORY ORGANS. 

invariable. Exceptions are observed. There may be no appreciable 
resonance on either side ; and with an abundant deposit on one side 
it may be equal on the two sides. This will be more likely to be 
observed in cases in which the abundant deposit is seated in the left 
side ; and under these circumstances, the equality of resonance may 
be evidence of an abnormal increase on the left side, assuming that 
there existed a natural disparity in favor of the right side. I have 
observed the vocal resonance to be more marked at the summit of the 
right side, when other physical signs showed an abundant deposit in 
the left lung, the resonance on the affected side either not being ex- 
aggerated, or not sufficiently so to equal that which naturally existed 
on the opposite side. 

Bronchophony, as distinguished from exaggerated vocal resonance, 
is observed in a less proportion of cases. Not unfrequently, however, 
it is strongly marked. I have observed, in connection with a more 
abundant deposition in the left, than in the right lung, both sides 
being affected, that the vocal resonance was greater on the left side, 
while weak bronchophony existed on the right, and not on the left 
side. 

I may repeat here, what has been said already in the chapter on 
pneumonitis, and in the first part of this work, that when broncho- 
phony exists, it is generally a persistant sign, not disappearing and 
reappearing at successive examinations, as is assumed by Skoda. It 
does not sustain any fixed relation to the bronchial respiration. I 
have in several instances observed strong bronchophony in cases in 
which a respiratory sound was so feeble as to be scarcely appreciable, 
and conversely, there may be an intense bronchial respiration without 
marked bronchophony. This is a discrepancy not easy to reconcile, 
if both phenomena are explained by consonance, according to the 
theory of Skoda. 

A bellows-sound accompanies whispered words more uniformly, 
and is more intense and acute, cceteris paribus, in proportion to the 
abundance of the tuberculous deposit. This sign may be present in 
a notable degree, when the bronchial respiration, bronchophony, or 
exaggerated vocal resonance are not strongly marked. 

In cases of tuberculous disease advanced to the formation of cavi- 
ties, more or less solidification of lung remains ; and hence, the aus- 
cultatory pheuomena just described, do not altogether disappear, 
although they may be diminished, combined with, and to some 
extent replaced, by other signs. The characteristics which distin- 



PULMONAEY TUBEKCULOSIS. 481 

guish. this period in the clinical history of tuberculosis, consist in the 
addition of cavernous signs to the phenomena denoting solidification. 
It suffices, then, to inquire, what are the cavernous signs furnished by 
auscultation, and to what extent are they available in diagnosis ? 
As regards cavernous respiration, observations directed more espe- 
cially to the variations in pitch of respiratory sounds, have led me to the 
conclusion, in opposition to high authority, that the ingress and egress 
of air, to and from an excavation of an adequate size, under favorable 
circumstances; may be readily distinguished; that the cavernous and 
the bronchial respiration are not, so far as audible characters are con- 
cerned, identical ; and that the normal laryngo-tracheal respiration is 
the type of the bronchial, but not of the cavernous respiration. The 
distinctive features of the cavernous respiration have been con- 
sidered at some length in Part I. It is sufficient to reproduce a 
simple enumeration of them here. They consist of an inspiratory 
sound, non-vesicular or blowing, but compared with the bronchial in- 
spiration low in pitch, hollow, more slowly evolved ; and of an expi- 
ratory sound, if present, lower in pitch than the sound of inspiration. 
A fair number of observations in which these features of the respira- 
tion were localized during life, and found to correspond in their situ- 
ation with cavities ascertained to exist after death, have led me to 
entertain the belief, that the existence and seat of excavations may 
be predicated on the auscultatory characters just mentioned, when- 
ever they are distinctly manifested. But owing to the number of 
circumstances which must be combined, in order that a cavernous 
respiration may be developed, it will often happen that when cavities 
have formed, examinations fail to discover the evidence of their 
existence. Indeed, it is often only after repeated explorations, made 
at different times, and conducted with much care and patience, that 
they are detected. For an account of the method of prosecuting a 
search for cavities, and of the circumstances upon which the develop- 
ment of the cavernous respiration depends, the reader is referred to 
that portion of the chapter on Auscultation, in Part I, which is 
devoted to this subject. 

The cavernous respiration, like the bronchial, is by no iheans 
always presented, clinically, with the sum of its characters complete. 
The inspiratory sound may be alone present. Possibly this is true 
also of the expiration, but I cannot affirm that I have met with an 
instance. The lowness of pitch, together with the absence of the 
vesicular quality, are the points of distinction, when, an inspiratory 

31 



482 DISEASES OF THE EESPIRATORT OEGAXS. 

sound being alone heard, the contrast in pitch between this sound 
and that of the expiration is not available. Owing to the solidifica- 
tion generally surrounding tubercular excavations, the bronchial 
respiration is frequently present in the immediate vicinity of the 
cavernous, and by means of this comparison, the characters of the 
latter are rendered more conspicuous. 

If the distinctive features of the cavernous respiration are mani- 
fested within a circumscribed space, and the characters of the bron- 
chial respiration surround this space, the localization of an excava- 
tion may be made with confidence. The evidence is rendered still 
more complete, if at different periods of the day the cavernous respi- 
ration is found to be sometimes present, and at other times absent, 
and more especially if, when found to be absent, it is observed to be 
reproduced after an abundant expectoration. And if over this space 
a circumscribed tympanitic resonance on percussion is found to co- 
exist with the cavernous respiration, and to disappear when it ceases, 
the resonance perhaps presenting a metallic or cracked-vessel intona- 
tion, nothing more could be desired to strengthen the proof of the 
seat of a cavity. 

In some cases a cavernous respiration is not thus circumscribed, 
but is more or less diffused over the summit of the chest. The con- 
ditions which may be supposed to exist in these cases are either a 
very large excavation, or numerous cavities, which if they do not 
communicate, are situated in close proximity to each other, the 
aggregate amount of excavation being sufficient to cause a predomi- 
nance of the cavernous over the bronchial characters of the respira- 
tory sound. On the other hand, if cavities exist, which are small in 
size, and not numerous, the intervening solidification causes a pre- 
dominance of the bronchial over the cavernous characters, so that, 
under these circumstances, auscultation fails in discovering the exis- 
tence of excavations. In auscultating patients with tuberculosis more 
or less advanced, the cavernous and the bronchial respiration seem 
to me not infrequently to be combined ; in other words, the respira- 
tion appears to present the characters of these two modifications 
mixed, the cavernous predominating in some cases and the bronchial 
in others. The existence of cavities may be predicated on such a 
combination, although their size and situation are not determined. 
This combination might with propriety be styled a hronclio-cavernous 
respiration. 

An amphoric intonation is probably conclusive, in itself, of the 



PULMONARY TUBERCULOSIS. 483 

existence of a cavity. This variety of the cavernous respiration is, 
however, rarely present in tuberculous excavations. 

Gurgling, also, -when well marked, is sufficient proof that the dis- 
ease has advanced to excavation ; but as the sound is more or less 
diffused, it does not serve to fix the precise location of the cavity so 
well as the cavernous characters of the respiration. 

A cavernous vocal sign is transmission of speech, i. e. articulate 
words, to the ear applied over the seat of an excavation. Pectorilo- 
quy, however, as this sign is called, is not exclusively a cavernous sign. 
It occurs, perhaps more frequently, over solidified lung, and, hence, 
it is occasionally observed over a mass of crude tubercle before the 
disease has advanced to the formation of cavities. For this reason, 
and from the fact that it is very rarely discovered where cavities 
exist, on account of a combination of various contingencies being 
indispensable to its production, it possesses very little value, clini- 
cally, as evidence of an excavation. Circumstances which render it 
distinctive, as a cavernous sign, are its being limited to a circum- 
scribed space ; its occurrence without being associated with marked 
exaggerated vocal resonance, or strong bronchophony; its inter- 
mittency, and its coexistence with cavernous respiration and a tympa- 
nitic percussion-resonance (with or without the amphoric or cracked- 
metal intonation) confined within the same limits. An amphoric 
resonance, produced by the voice, is a rare vocal phenomenon, which, 
when present, is, in itself, more distinctive of a cavity than pecto- 
riloquy. 

The act of coughing may develope auscultatory phenomena which 
are highly significant of tubercular excavation. When a cavity of 
considerable size and superficially situated Is empty, the violent expi- 
rations incident to coughing occasion, within a circumscribed area, a 
hollow, blowing sound, sometimes accompanied by a forcible shock 
against the ear applied to the chest. If the cavity be partially filled 
with liquid, a loud gurgling or splashing noise is frequently produced. 
The latter is eminently a cavernous sign. 

Finally, the physical sign which is at once a respiratory, vocal, 
and tussive sign, viz., metallic tinkling, is occasionally produced in 
connection with a large pulmonary excavation. The conditions for 
its production are only present when the cavity is extremely large, 
and when it contains liquid and air in certain relative proportions. 
It is so rarely incidental to a tuberculous cavity, that it is only inte- 
resting in this connection as a clinical curiosity, and as furnishing an 



484: DISEASES or THE KE5PIRAT0RT ORGA^'S. 

exception to the rule, that it denotes perforation of the lung and 
pneumo-hydrothorax. 

In employing auscultation in cases of suspected tuberculosis, the 
attention is, of course, as in practising percussion, to be directed 
especially to the summit of the chest, in view of the fact that in the 
vast majority of cases a tuberculous deposit takes place first and 
chiefly at or near the apices of the lungs : the occasional exceptions 
to this law will be hereafter noticed. In auscultating as in percuss- 
ing the chest for the evidences of tubercle, it is equally important to 
examine behind, over the scapulae, as in front. The post-clavicular 
space is not to be overlooked, provided the physical evidence of the 
disease be not sufficiently distinct in other situations. The pheno- 
mena discovered by auscultation, as well as those developed by per- 
cussion, are to be compared on the two sides of the chest, corre- 
sponding points being successively explored. The respu-atory sounds 
being examined first on one side and next on the other side, and 
contrasted with each other, the observer is to decide whether these 
sounds are equal on both sides. A disparity between the two sides 
(making due allowance for certain natural differences) indicates dis- 
ease. The sounds on both sides may be abnormal, but a law of tuber- 
culosis determines almost invariably the evidences of a greater 
amount of disease on one side than on the other. Having discovered 
that a morbid disparity exists, the next step is to analyze the sounds 
on each side, and ascertain the characters which are morbidly pre- 
sented. These elementary characters relate to the intensity, quality, 
pitch, duration, and rhythmical succession of the inspiration and the 
expiration. After such an analysis we refer morbid alterations to 
their appropriate place in the catalogue of physical signs : in other 
words, we determine whether there be present a broncho-vesicular, 
a bronchial, or a cavernous respiration. The coexistence or the 
absence of adventitious sounds, or rales, are at the same time ascer- 
tained. It is frequently useful to compare the phenomena found 
not only in corresponding points on opposite sides, but in different 
portions of the same side. For example, the respiratory sounds over 
the scapula, above and below the spinous ridge, may present striking 
points of contrast ; as, also, the post-clavicular and the infra-clavi- 
cular regions in front, and different parts of the latter region. The 
upper third of the chest may be compared with the middle and lower 
thirds, in order to judge by contrast with respect to morbid changes. 
The chest-sounds may be brought into comparison with the laryngo- 



PULMONARY TUBERCULOSIS. 485 

tracheal, when it is desired to compare the former with the type of the 
bronchial respiration. Similar comparisons are to be instituted with 
respect to vocal phenomena. 

The different methods of auscultation have been sufficiently con- 
sidered in the first part of this work ; but I avail myself of this 
opportunity to bear testimony to the value of the stethoscope recently 
introduced by Dr. Cammann. Since the chapter on Auscultation, in 
Part I, was written, several months have elapsed, and in the mean 
time I have been in the habit of using this instrument more or less, 
almost daily. In cases of suspected tuberculosis, in which tuberculous 
deposits are either wanting, or are small and disseminated, by means 
of this stethoscope a closer comparison of the respiratory sounds can 
be made than with the ordinary cylinder or the naked ear. A dis- 
parity, therefore, on the one hand, is in some instances rendered 
appreciable which otherwise would not be discovered ; and, on the 
other hand, the absence of a disparity, and the completeness of the 
normal characters, are more satisfactorily determined than is always 
practicable without this improved means of auscultatory exploration. 
It enables the auscultator to study the characters of the respiration 
in some cases in which it is so feeble as to be with difficulty appre- 
ciated by the ordinary cylinder or by immediate auscultation. Its 
usefulness in cases in which it is desirable to make nice comparisons 
with respect to vocal phenomena, is not less than in examinations 
with reference to respiratory sounds. These advantages render the 
instrument particularly serviceable, both in a positive and negative 
point of view, in the diagnosis of pulmonary tuberculosis. 

I^aspection furnishes signs of tubercular disease, consisting of 
morbid appearances which pertain to the size and form of the summit 
of the chest, and to the respiratory movements in this situation. 
Some depression on the affected side, and diminished expansion with 
inspiration, are apparent in a small proportion of cases, at an early 
period, when the quantity of tuberculous matter, so far as it can be 
estimated by means of other signs, is small. A disparity in size and 
motion, although less frequently observed at this period than subse- 
quently, is of more importance than when the quantity becomes 
abundant, because the diagnosis, in general, is only difficult so long 
as the disease has not made much progress. After the deposit has 
attained to a certain amount, involving considerable solidification, 
the evidence of its existence derived from the combination of different 
signs is sufficiently clear and decisive. The obstruction to full ex- 



486 DISEASES OF THE RESPIRATORY ORGANS. 

pansion of the upper portion of the Inng. and the collapse of air-cells 
produced hj a few small disseminated tubercles, may occasion an 
undue depression either above or below the clavicle, or in both situa- 
tions, ascertained by comparison of the two sides. Moreover, circum- 
scribed pleuritis, leading to the formation of false membrane, and 
thereby tending to contract the apex and restrain its expansion, 
belongs frequently to the early history of tuberculosis, as is evidenced 
by the symptoms. In comparing the superior costal movements of 
the two sides, observing the precautions pointed out in Part I, in the 
chapter on Inspection, the effect of forced as well as tranquil 
breathing is to be observed. Owiug to the limited amount of expan- 
sion at the summit of the chest in ordinary breathing, a disparity in 
males is rarely developed except when the intensity of respiration is 
increased : and in females, in consequence of the habitual predomi- 
nance of the sujDerior costal type, a disparity is manifested earlier, 
more frequently, and ia a more marked degree. Mensuration, by 
means of the graduated inelastic tape, but more especially with the 
chest-measui'er of Dr. Sibson, or the stethometer of Dr. Quain, will 
show a disparity in expansive motion with greater precision. For 
clinical purposes, however, inspection suffices. Callipers also enable 
the explorer to determine, with proper care, the exact amount of 
variation between the two sides in their antero-posterior diameters. 
But this exactness, for ordinary practical purposes, has no advantage 
over the information obtained by the readier and more simple 
method of comparing with the eye. It is not to be forgotten that a 
want of symmetry between the two sides, due to curvature of the 
spine, former pleurisy, or other causes, occasions more or less dis- 
parity in size and expansibility, irrespective of present disease ; and 
even when no want of symmetry in the general conformation of the 
chest is discoverable, a slight difference in the curves of the clavicle 
may cause the regions above and below this bone to appear on one 
side relatively somewhat depressed. In making observations on the 
healthy chest, I have observed that occasionally, even when it appears 
to be perfectly well formed, there exists a slight disparity in motion 
at the summit. Isolated from other signs, therefore, variations in 
size and expansibility, if slight, possess very little diagnostic value. 
Their importance depends mainly on their connection with other 
signs, and with symptoms which render probable, if not certain, the 
conclusion, that they are due to a morbid cause. 

At a later period in the progress of the disease, when the tuber- 



PULMONAET TUBERCULOSIS. 487 

cular solidification is considerable, and when, as already remarked, 
the signs furnished by inspection or by mensuration are of less 
importance in the diagnosis, the depression at the summit and the 
defective expansion, are generally conspicuous. The cases are few 
in number in which these signs are wanting. Of 35 recorded examina- 
tions, in different cases, in which the appearances on inspection were 
noted, in all but 4 there was either abnormal flattening, or diminished 
superior costal motion, or both were combined. The latter was 
oftener observed than the former, but in the majority of instances 
depression and deficient expansion coexisted. Depression is gene- 
rally made apparent by the greater projection of the clavicle, but it 
is sometimes the case, as remarked by Walshe, that this bone follows 
the retreating ribs, and then the greater concavity above and the appa- 
rent flattening below may be on the side least afi'ected. I have met 
with instances of this description. In such cases callipers are requisite 
to demonstrate the side on which exists the real reduction in size. 

As would be rationally inferred, a disparity between the two sides, 
at the summit, in size and expansibility, continues after tuberculosis 
has advanced to the formation of cavities. It is stated by Walshe 
that in some cases in which a very large cavity is formed, the depres- 
sion is less marked than at a prior period, and the expansion move- 
ment may be increased. An increase of size under these circum- 
stances would hardly be expected a priori, and its occurrence might 
fairly be distrusted, except it had been positively ascertained by 
careful comparative measurements at diff"erent periods. The in- 
creased expansibility is more intelligible. A bulging in the inter- 
costal spaces over a circumscribed space, with the act of coughing, I 
have in some instances observed, an appearance indicating the site of 
a large cavity, with its walls situated near the superficies of the 
lung, and the pleural surfaces adherent. 

Palpation may furnish information of some utility in its bearing 
on the diagnosis of pulmonary tuberculosis. The increased sense of 
resistance to pressure over tubercular solidification, is ascertained by 
this method more satisfactorily, than incidentally in the practice of 
percussion. By placing the hand on the summit, the extent of ex- 
pansive movement can be estimated, and the two sides compared in 
this respect. But it is especially with respect to the vocal fremitus 
that this method of exploration is applicable. Its utility in this 
point of view is comparatively slight. An exaggerated fremitus is 
an occasional, not a constant, efi'ect of increased density of lung. 



488 



DISEASES OF THE RESPIRATORY ORGANS. 



Even when solidification is complete and extensive, as it is in some 
cases of pneumonitis, an appreciable exaggeration of the fremitus is 
by no means uniform. In the partial and imperfect solidification 
from tubercle, the sign is often wanting : especially in the early 
period of tuberculosis, when it is most valuable, it is rarely present. 
Another reason for the frequent unavailability of this sign is the 
disparity between the two sides as regards the normal amount of 
fremitus. It is habitually greater on the right side. Equality in 
this particular constitutes the exception rather than the rule. This 
fact renders the sign almost nugatory in cases in which a greater 
fremitus is found on the right side. Observations show that the fre- 
mitus may continue greater on the right side, when other signs indi- 
cate unequivocally an abundant tubercular deposit on the left side. 
But this normal difference between the two sides renders the sign, in 
some instances in which it exists on the left side, more significant 
than it would be, were the two sides equal in health. A vocal fre- 
mitus existing on the left and not on the right side, or more marked 
in the former situation, is, in fact, highly significant, but the coex- 
isting: signs, under these circumstances, leave no room for doubt as to 
the fact of solidification of the lung. In accumulating, however, data 
from every quarter, in order either to render the proof of tuberculous 
disease perfectly conclusive, or, on the other hand, to exclude the 
disease, comparison of the two sides as respects vocal fremitus should 
not be overlooked, although the information, positive and negative, 
derived from other methods, is vastly more important. 

Finally, a succussion-sound, or splasliing, has been observed when 
a large tubercular cavity is partially filled with liquid. It is suffi- 
cient simply to mention this fact. The sign belongs in the list of 
phenomena denoting a cavity, but it is so rarely available that the 
importance of resorting to this method of exploration hardly need be 
recommended. 



Diagnosis. — Pulmonary tuberculosis, although embracing in its 
career most of the phenomena furnished by the different methods of 
exploration, has no special pathognomonic physical signs. The phe- 
nomena which it embraces belong also to other affections. They 
represent morbid conditions not peculiar to tuberculosis, but existing 
in other forms of disease. Isolated from other signs, and dissevered 
from symptoms, pathological laws, and associated circumstances, none 
of the physical phenomena which have just been considered would 



PULMONARY TUBERCULOSIS. 489 

possess marked diagnostic importance. Nevertheless, from their 
combinations, their conjunction with vital phenomena and with facts 
pertaining to the natural history of the disease, they acquire a posi- 
tive value, and are hardly less significant than if they belonged to it 
exclusively. 

These general remarks are alike applicable to the symptoms. The 
semeiology of pulmonary tuberculosis embraces a series of events 
which are common to this and other affections, and which, in a diag- 
nostic point of view, derive their importance chiefly from association 
with each other, from coexisting physical signs, accompanying cir- 
cumstances, and the laws of the disease. 

The diagnosis of pulmonary tuberculosis is based on the positive 
evidence of its existence. If this evidence is present, we do not call 
to our aid, save to a very limited extent, the mode of investigation 
called " reasoning by way of exclusion." The differential diagnosis 
from other affections hinges mainly on the presence or absence of 
the signs and symptoms which denote a tuberculous deposit. We do 
not, in other words, undertake to exclude other affections, but, on 
the other hand, w^e direct our investigation to ascertain whether 
there is sufficient proof of the existence of tuberculosis. Hence it 
follows, that in order to make the discrimination clinically, and to 
decide correctly whether a patient be affected with this disease or 
not, the physician must be acquainted w^ith its symptoms and signs, 
and understand the conditions under which they constitute positive 
evidence of its existence. The physical signs have been considered. 
It remains now to enumerate the symptoms prominently involved 
in the diagnosis. The latter I shall notice very briefly, limiting the 
attention exclusively to diagnostic points. And inasmuch as the 
diagnosis very rarely presents difficulty, except at an early period, 
before the disease has made much progress, those points which have 
relation to its development and incipient stage, are chiefly important. 

The circumstances, then, which invest the various symptoms attend- 
ing the development and progress of pulmonary tuberculosis with 
diagnostic significance are the following. A cough, not originating 
from a distinct attack of acute bronchitis, and not preceded by coryza, 
but frequently commencing so imperceptibly that the date of its 
first appearance cannot be definitely ascertained ; in degree slight, 
moderate, or violent, but persisting for some time with little or no 
expectoration. Dryness of the cough, continuing for a greater or 
less period, according to my experience, obtains in a larger ratio of 



490 DISEASES OF THE KE5PIRAT0RY ORGANS. 

cases than is estimated by Walslie, viz., one-tenth. I should say that 
careful inquii-y of patients will show it to he the rule. An expecto- ' 
ration at &st small, transparent, and frothy ; becoming gradually 
more abundant, solid, opaque, yellow, and non-aerated, subsequently 
consisting of sputa streaked with yellow lines, particolored, and 
frequently presenting irregular ragged edges ; occasionally including 
small particles resembling boiled rice, and a grumous-looking sub- 
stance contained in a thinner fluid, like the deposit in barley water. 
According to Walshe, from whom is borrowed the description of the 
appearance last named, such a deposit occurs only in cases of phthisis. 
At a more advanced period purulent matter, in greater or less abun- 
dance, runninoj toorether and forminor an ash-colored mass, with a 
nauseous and occasionally fetid odor. Small fibres, supposed to be 
exfoliated elastic tissue, discovered by microscopical examination ; 
also detached fragments of other of the anatomical elements of the 
pulmonary structure, and possibly, in some instances, the tubercular 
corpuscle. Acute stitch-pains at the summit of the chest, sometimes 
in front, oftener beneath the scapula ; recurring from time to time ; 
at times severe, and lasting for several days ; in other instances slight 
and of brief duration ; experienced more frequently on one side than^ 
on the other, but often occurring successively, or in alternation, on 
both sides. These pains generally denote repeated attacks of cir- 
cumscribed pleuritis. Chills, or shiverings, sometimes observing an 
approach to periodicity, and liable to be attributed to an ii'regular or 
imperfectly developed intermittent. Haemoptysis,* frequently the 
first symptom to create alarm in the mind of the patient ; sometimes 
preceding other symptoms, and all appreciable physical signs.^ In- 
creased frequency of the respirations, other things being equal, the 
increase proportionate to the abundance and rapidity of the tubercu- 
lous deposit : want of breath on slight exertion, and in some cases 
dyspnoea; acceleration of the pulse, not invariably but generally 
present, and frequently a marked symptom ; a vibratory or thrilling 
character, together with frequency of the pulse, the latter occurring 
when the tuberculous afi"ection is actively progressing. Nocturnal 
perspu'ation, occurring frequently at an early period, as well as 

^ The subject of hemoptysis in its relation to tuberculosis, has been elaborately inves- 
tigated by Dr. Walshe 5 vide British and Foreign Medico-Chir. Review, January, 1849. 

* In 91 of the 100 cases \irhich I have analyzed, as respects physical signs, the histo- 
ries contain information concerning haemoptysis. It had occurred in 53 cases prior to 
the time of my examinations. Of 22 cases of small tubercular deposits, it had occurred 
in 13. Of 11 cases in which the existence of cavities was ascertained, it had occurred 
in 6. Of 58 cases of abundant deposit, it had occurred in 34. 



PULMONARY TUBERCULOSIS. 491 

when the disease is advanced, in the latter case preceded by febrile 
•movement, and forming an element of hectic paroxysms. Diarrhoea 
frequently recurring or persisting, denoting intestinal tuberculosis ; 
this complication in some instances developed at an early period, but 
generally after the pulmonary affection is considerably advanced. 
Chronic peritonitis, which is very rarely developed, except as the 
result of tuberculous deposit, consequent to pulmonary tuberculosis, 
and, therefore, inferentially evidence of the existence of the latter. 
Chronic laryngitis, which does not precede the pulmonary disease, as 
was formerly supposed, but indicates a tuberculous affection of the 
larynx, succeeding the deposit in the lungs, and therefore indicative 
of the latter. Progressive loss of weight, diminution of the muscular 
strength, and a marked anaemic aspect, almost invariably accompa- 
nying and frequently taking precedence of prominent pulmonary 
symptoms. Finally, mental buoyancy and freedom from apprehen- 
sion on the score of disease. This list might be extended, by the 
addition of symptomatic characters incident to a period of the disease 
when the diagnosis is rendered sufficiently easy by obvious symptoms 
as well as by physical signs. 

In a case in which are combined the greater part of the diagnostic 
points just enumerated, there would be very little room for doubt 
that the patient was affected with pulmonary tuberculosis. Physical 
exploration, however, would at once supply additional points, giving 
to the evidence of the existence of the disease nearly the force of 
demonstration. The physical phenomena would consist of those 
denoting increased density or solidification of lung, on the summit of 
the chest, on one or both sides, with perhaps the addition of the signs 
of cavities. If, in a case such as is now supposed, presenting a collec- 
tion of symptoms indicating, with a high degree of probability, tuber- 
culosis, this disease really exists, the physical evidence of its existence 
is almost invariably positive and easily discovered. But cases fre- 
quently present themselves in medical practice in which the diagnostic 
symptoms are less marked. For example, in conjunction with cough, 
which is perhaps slight, or, in itself, insignificant, together with a 
morbid aspect, there may be simply a moderate loss of weight and 
strength, neither being very apparent to the patient, and yet physi- 
cal exploration may reveal an abundant tuberculous deposit. With- 
out the aid of physical signs in such a case, there is only room for 
the suspicion of tuberculosis ; with their aid, the existence of the 
disease is determined promptly and in the most positive manner. 

To cite another example : a patient may be attacked with haemop- 



492 DI = 5i-5E= CI IE 



i, :: r ^ r. ^ A V j:* A 



I 






~ : ne diagnosde eharacters 

: i^ *: be remaiked tiiat 

^ ; : ->^ le. This is troe of 

Lions eompiications, Tiz., mtestmal, peii- 

i: : tjsis occurs in only a certain propor- 

:: on is large. The loss of weight and 

1 may be dne to a variety of mor- 

Chills and pleurifie pains are 

,^^ :z ::3? depends on their being 

is not invariably aecele- 

= ' in freqaency. The 

- : _ i expectoralicHi may 

_ : ; T^ <»f tubercoloiis 

z:^ : i for some 

. \' t: ■ T -. ;:.::__:.._. :::i- "history 



toneai, ar. ,. . " : _ r j:. r 

tion of ca.= t 

strength is l : : ~ ^ — 

bid conditi :i - : r : 

not etmsts' : t i: 

associated -:_- ::..:- --:__: 

rated, and : i : 

distinctive 

be absent. ^ 

disease by 

time, in ti: „ 

andpreser: L 

positive, -c ' : : ;_ 

Ions depC'^ 

changes 11 :_ _ . 

their existence. il t : 

bearirr ''-i 'iir -:.'/:- ;: ■ 

tnberc -i ; It '.-:•:: -iz:::t_ 

a patient to seek for med: 

without diffienlty by carefn 

the stadoit or young prac- 

notion, from the str^ which is very properlj . l 

and ^gns concorring to establish the diagnos : - 

tob^'cles. That instances do occur in whi^il :_7 

from symptoms and signs, conjointly, are slight, -i 

consequently attended with difficulty, must be ado: 

of this kind are exceptions to the general rule. *. : 

pected tuberculosis which the phym<nan meets witi: : :. 

disease really exist, the phy^cal ^gns, in eonjon 

sympton^ are positive and easily det^rvshi'^ in th^ 



-r. : . : : : _t. -':.. .ess a 

: . _ T .:.-;_ : :i«rcu- 

:: : i.jsical 

„ ; ^1: :_ l::ating 

ed, is highly important in its 

~' 'oration in this disease. A 

'/^ the symptoms which lead 

iiost invariably detected 

:" L. On this subject, 

ierire an incorrect 

the symptoms 

- is^seminated 

1 ? e derived 

: _ 7 . . : _■ L ]*sis is 

:ances 



-.e 



PULMONARY TUB EEC UL S IS. 493 

This opinion is based on a pretty extensive experience for the last ten 
years. Let the student, or the practitioner who is not accustomed to 
physical exploration, then, not be repelled by the erroneous idea that 
the diagnosis of tuberculous disease very often hinges on points so 
delicate and difficult to be appreciated, as to compel him to rely in 
most cases on the symptoms alone. This idea, which I know to be 
common, does injustice to the subject of physical diagnosis. 

An important practical question is, how few physical signs, taken 
in connection with symptoms pointing to tuberculous disease, are 
sufficient to establish the diagnosis ? The physical phenomena in- 
cident to a deposit of tubercle by no means always correspond in 
amount with the diagnostic characters pertaining to the symptoms. 
A case may present symptomatic circumstances strongly indicating 
the disease, and the signs be found not to be proportionately marked. 
On the other hand, it much oftener happens that while the symptoms 
alone would leave the- diagnosis extremely doubtful, the physical 
evidence is abundantly conclusive. Assuming the existence of cer- 
tain symptoms which give rise merely to a suspicion of tuberculosis, 
for instance, a persisting cough, with loss of weight and a pallid com- 
plexion, provided the chest be symmetrical, if on examination a dis- 
tinct dulness, however slight, is discovered at the summit of the left 
side, in front, or behind, and especially in both situations, together 
with an obvious modification of the respiratory murmur, consisting in 
diminished vesicular quality, with elevation of pitch of the inspira- 
tion, or in a prolongation with elevation of pitch of the expiratory 
sound, in short, more or less of the elementary characters of the 
broncho-vesicular respiration, the diagnosis is rendered nearly if not 
quite conclusive. The addition of a highly significant symptom, viz., 
haemoptysis, and of an equally significant sign in this situation, 
viz., increased vocal resonance, scarcely leaves any room for doubt. 
If these same physical phenomena (which it is assumed are slight), 
are found at the summit of the right side, the evidence is less con- 
clusive. Contingent or accidental signs are then of much more im- 
portance, as showing that the disparity is due to a morbid condition, 
and not to a natural difference between the two sides. A persisting 
or frequently recurring sibilant rale, a fine mucous or sub-crepi- 
tant rale, or dry crackling, limited to the summit, render it alto- 
gether probable that the disparity is morbid, and hence, these signs 
become highly valuable as diagnostic indications. Their value is 
much less, under the circumstances supposed, on the left side, be- 
cause they are comparatively superfluous. 



494 DISEASES OF THE EE5PIRAT0RT 0RGAX3. 

Will an amount of physical evidence still less than has just been 
assumed suffice for the diagnosis? Pertinent to this inquiry it may 
be stated, as a rule, that the amount of physical evidence required for 
the diagnosis is small in proportion as the rational evidence is abun- 
dant ; in other words, if the diagnostic circumstances relating to the 
history and symptoms tend very strongly to the opinion that tuber- 
culosis exists, fewer and less marked signs are needed, pro"vaded, such 
as they may be, they are distinct and unequivocal in their character. 
In point of fact, under these circumstances, the physical signs are 
generally sufficiently numerous and striking. Assuming, however, 
that in conjunction with certain significant symptomatic characters, 
the only physical phenomena discovered ure of the class which I have 
distinguished as contingent or accidental, viz., bronchial rales, crepi- 
tation, and dry crackling, within a limited area near the apex of the 
hing, these signs would authorize a higMy probable although not a 
positive diagnosis. But judging from my own experience, I should 
never expect to find these phenomena persisting or present in a 
marked degree without, at the same time, discovering disparity in the 
percussion-resonance and in the respiratory murmur. 

x^mong the circumstances which, in a rational point of view (as 
distinguished from physical phenomena), are entitled to weight in the 
diagnosis of pulmonary tuberculosis, hereditary influence may fairly 
be included. The statistical researches of Walshe appear to lead to 
the conclusion that this influence may have been overrated. But 
while we witness, as we do not infrequently, a family of children 
springing from a tuberculous parentage swept off in succession by 
this disease, we cannot doubt that it involves in such instances a con- 
genital predisposition.^ Age is also entitled to consideration, since 
it is sufficiently established that the development of the disease is 
much more likely to take place between 20 and 40, than prior or 
subsequent to these periods of Kfe.* 

Another important practical question is the following : Does the 
absence of any apparent disparity between the two sides, no adven- 
titious sounds being discovered, the percussion-resonance remaining 
clear and vesicular, and the respiratory murmur apparently normal, 

^ A remarkable instance of this kind recently came under my notice. In the space 
of five years 7 children died of phthisis, all between IS and 23 years of age. They 
constituted all the children in the family. The mother died of phthisis shortly before 
the death of the first child, aged 45 years. The disease was developed shortly after 
confijiement, and the child died in infancy. The father is living and in robust health. 

' Vide statistical researches of M. Lombard. Yalleix, op. cit 



PULMONARY TUBERCULOSIS. 495 

warrant a positive opinion that tuberculosis does not exist ? This ques- 
tion is equivalent to the inquiry, whether a tuberculous deposit may- 
exist in the lungs in a latent form so far as concerns physical signs. In 
its clinical bearing this question has, in fact, been already virtually 
answered. I have said, that whenever there are present symptoms 
warranting a strong suspicion of a tuberculous aifection, which in 
reality does exist, it may be confidently expected that the physical 
evidence of its existence will be discovered; and, moreover, this evi- 
dence will often be found when the symptoms do not strongly indi- 
cate the disease. That tuberculous deposit may be so small in quan- 
tity and so distributed as not to give rise to appreciable physical 
signs, I do not doubt. Autopsical examinations of persons dead with 
different diseases, appear to show that small depositions not infre- 
quently take place, which remain dormant, become obsolete, or pass 
through their changes on a minute scale, the ulterior morbid con- 
dition on which the deposit depends being from some cause arrested. 
In these cases it is probable that the disease is frequently latent 
as respects diagnostic symptoms not less than physical signs. At all 
events, judging from clinical experience, if on careful and repeated 
explorations, the resonance on percussion and the respiratory mur- 
mur are found to be normal and equal on the two sides, no adven- 
titious sounds being present, it is quite safe to consider the patient 
non-tuberculous. A practitioner will, of course, feel greater posi- 
tiveness in the negative result of his examinations, in proportion to 
his confidence in his tact in exploration, and his ability to appreciate 
and compare physical phenomena. Moreover, he is not bound to 
commit himself and the art to an unqualified opinion, whatever may 
be the strength of his private conviction. It is enough that he state 
the absence of appreciable evidence of the existence of the disease. 
Discretion is, however, to be exercised in giving more positive assu- 
rances, in cases in which the remedial influence of their moral efi'ect 
is desirable. It seems gratuitous to add that the prudential course 
just alluded to is the more politic the less the experience of the phy- 
sician in physical exploration ; but it often happens that patients are 
pronounced free from tuberculosis, when subsequent events show that 
the hopes and wishes of both patient and physician had much to do 
in determining this conclusion. 

The absence of apprehension which characterizes the mental condi- 
tion of persons aff"ected with tuberculosis, often makes them tardy in 
seeking medical advice. This is one reason why, in the majority of 



496 DISEASES OF THE RESPIRATORY ORGANS. 

cases, when patients first feel the need of resorting to a physician, 
the diagnosis is sufficiently easy. On the other hand, in various affec- 
tions in which the mind is differently affected, the apprehension of 
consumption is a source of great anxiety, and it is the dread of this 
disease which leads patients to desire a physical exploration of the 
chest. The timidity and agitation which are sometimes manifested 
during an examination, and the solicitude shown respecting the 
result, constitute some ground for a presumption that tuberculosis 
does not exist. 

Of the different non-tuberculous patients whose fears of the disease 
bring them under the cognizance of the physician, a portion suffer 
from neuralgic pains in the chest, in conjunction with more or less of 
the numerous ailments sometimes grouped under the title of spinal 
irritation. This class embraces females in much the larger proportion. 
They are usually anaemic and affected with uterine disorder of some 
sort, together with, not infrequently, hysterical symptoms more or 
less marked. Judging from the rare instances in which, so far as 
my observations go, tuberculosis is found under these circumstances, 
I should say that the morbid condition referred to, to say the least, 
does not involve any predisposition to the disease. It is not common 
to find well-marked spinal tenderness in tuberculous patients. 

Another class consists of dyspeptics. The hypochondriasis which 
forms so constant and prominent a feature of the affection known as 
dyspepsia, induces suspicion and sometimes a fixed conviction that 
phthisis exists, even when there are no pulmonary symptoms whatever. 
Tuberculosis has been supposed by some distinguished authors to be 
often preceded and accompanied at its commencement by notable 
disorder of the digestive function.^ Such has not been the fact in 
my experience. I have not observed that dyspeptics are prone to 
become affected with tuberculous disease ; and, conversely, tubercu- 
losis has seemed to me oftener than otherwise to originate without 
being attended by any marked evidence of gastric disorder. So 
far, then, from dyspepsia constituting any ground for anticipating 
that the evidence of tubercles will be discovered, I have come to re- 
gard it in an opposite light. 

Another class, and for the last few years perhaps the most numerous, 
is composed of persons affected with chronic pharyngitis. Chronic 
pharyngitis is a common affection not only among clergymen, but with 
persons of different callings. The attention which has of late been 
directed to it has given it a popular as well as professional prominence ; 

■■ Wilson Phillip, Sir James Clarke, and Professor J. Hughes Bennett. 



PULMONARY TUBERCULOSIS. 497 

and the idea is generally held that it is a precursor of pulmonary tuber- 
culosis. Moreover, it is often accompanied by more or less cough 
and expectoration. Having had opportunities of observing numerous 
cases in which chronic pharyngitis has persisted for years, I am satis- 
fied that so far from the affection tending to tuberculosis, it is rather 
rare for the latter disease to become developed in this class of patients ; 
and, in fact, I have been led by experience to regard the former as 
militating against the presumption of the existence of the latter. 

Tuberculosis is apt to be suspected during the protracted convales- 
cence from chronic pleurisy, since it is inculcated by most writers that 
under these circumstances tuberculous disease is very apt to be secon- 
darily developed. Statistical researches show that chronic pleurisy 
is not, as is commonly supposed, prone to eventuate in phthisis.'' 
Tuberculosis, however, does occasionally become developed as a com- 
plication, and as a sequel. The diagnosis is attended with difficulty, 
owing to the fact that the presence of liquid effusion and its perma- 
nent effects prevent a comparison of the two sides of the chest. 
Moreover, chronic pleurisy is apt to be overlooked, and I have known 
the physical phenomena at the summit of the chest on one side due 
to the compression by a certain quantity of liquid, attributed to a 
tuberculous deposit, the presence of the liquid escaping observation 
from the exploration being limited to the summit. The permanent con- 
traction of the chest, if not great, is also liable to be overlooked, with- 
out careful attention, the patient perhaps not being aware that he has 
ever had chronic pleurisy, or not deeming it important to mention the 
fact if inquiries are not directed to that point, in endeavoring to deter- 
mine whether tuberculosis exists, or not ; under these circumstances, 
allowance is to be made for an amount of disparity between the two 
sides fairly attributable to the past or present pleurisy. The cha- 
racters of the respiratory sound on the affected side are to be carefully 
studied. The nearer they approach those found on the opposite side, 
the less ground is there to suspect a tubercular deposit. This supposes, 
of course, that the deposit, if it exist, is in the side affected with pleu- 
risy. The remark just made with respect to the respiration will also 
apply to vocal resonance. The result of an examination of the side 
not affected with pleurisy is important. Assuming the side first 
affected to be that in which the pleurisy is or was seated, according 
to a law of tuberculosis, a deposit will be likely to take place shortly 
afterward in the other lung ; hence, we examine for the physical 

' Vide Blakiston on Diseases of the Chest, and Essay on Chronic Pleurisy by Author. 

32 



T'lSEAiZS or IZZ I.ESPIEATOET 0E&A5"S. 

^eaMrtmg disease of tbe latter. The ei»iaiige3it phenomena, 
Tiz-, sibilaiit, nmcons, snb-erepitant rales, and dry cracklmg, if limited 
t» Aie sanHidt of the cliest on either side, and more especiaHj on the 
mS^ f^poHte to that affected idth tie r,>7-:i-. are highly significant 
when taken in connection -with e~'^ l^ —^^^ to tnhercnloTis dis- 
ease, snch as pnrnlent expif _ 'Tsis, and progressiTC 
emaciation- The latter are c:..^-^^ i. ^i.~.u.i "weight in the diag- 
nosis. I have tQO-wn, however, freqnent attacks of copious hemor- 
i^Lge to oeenr dming recoTery from chronic pleurisy, and snhse- 
qnently to reeoT-ery, vhen the other symptoms, the signs, and the issue 
rendered it prohahle that tuhercnlosis did not esist. 

The diagnosis of pnlmonaij tnhercnlosis heing hased, as has heea 
stated, on the positiye evidence of its existence derixed from physical 
signs and symptomii presented in combination, nnder circnmstances 
which render them distinctire of the disease, it is imnecessary to dwell 
on the discrimination from other affections with which it has some 
features in common. The differential diagnosis, in general, hinges 
mainly on the answer to this inquiry : Is there adequate positire proof 
^ tnhercnlosis? If an inrestigation of the phenomena, Tital and 
physical, derelope this proof, the existence of the disease is deter- 
miaed. If the resnlt of the inyestigation is negative, the diagnosis 
:id]s, and, ohserving proper care and caution, the disease may he ex- 
duded. Affections from which it is to he distingtdshed clinically, in 
addition to those already referred to in this chapter, are chronic 
bronchitis, chronic pnenmonitis, dilatation of the hronchia, and pnl- 
monary apoplexy. The points involved in the discrimination from 
likese affections, severally, will claim hnt a few words. With the ex- 
c^)4ie[Q of the affection last named (pulmonary apoplexy), these points 
have been mentioned in previous chapters. 

Chronic bronchitis does not commence with a slight and dry congh, 
accompanied by an expectoration at first small, transparent, and frothy, 
and becoming more abtmdant, sohd, and opaqne. On the contrary, it 
generally sncceeds the acnte form of the disease. Haemoptysis, 
plfinritie stitch-pains, chills, progresave marked emaciation, accele- 
ration of the respiration, frequency of the pnlse, night perspirations, 
are events which do not belong to its clinical history. The signs of 
solidification of the hmg and of pulmonary excavations are wanting. 
Tkm larfmchial rales, when present, are observed at the inferior poste- 
lior pairt ®f the chest, not li mi ted to a situation near the apex, and 
frequently confined to one side. 



PULMONARY TUBERCULOSIS. 499 

Chronic pneumonitis is exceedingly rare. When it occurs, it suc- 
ceeds acute inflammation. Acute pneumonitis, on the other hand, is 
rarely followed by a tuberculous deposit. The inferior lobe is the 
seat of pneumonitis in the great majority of cases, while a tubercu- 
lous deposit, commencing in the lower lobe, occurs only as an ex- 
tremely infrequent exception to a law of the disease. The liability of 
mistaking tuberculosis for chronic pneumonitis is greater than of taking 
the latter for the former. This error I have known to be committed. 
A case may present itself in which the error, for a time, would be 
very likely to be committed. An hospital patient, somewhat advanced 
in years, is admitted, with acute pneumonitis affecting the upper lobe. 
Taking the age into consideration, the situation of the inflammation 
is not remarkable. The appearance of the patient, and the previous 
history, which is not obtained at first with minuteness, owing to the 
inconvenience to the patient to reply to many questions, does not 
lead to a suspicion of tuberculosis existing prior to the pneumonitis. 
He passes through the acute disease in a favorable manner, and ap- 
pears to be rapidly convalescing. Cough and puruloid expectoration 
continue, and on physical examination, marked dulness, bronchial respi- 
ration, and bronchophony, are found to persist, with very little diminu- 
tion, at the summit of the chest, even after the patient has recovered 
from the pneumonitis sufliciehtly to be up and dressed. For a little 
time these physical signs are supposed to indicate a slow resolution 
of the inflammatory solidification. Their continuance, however, 
leads to a more minute investigation of the case, when it is ascer- 
tained that cough and expectoration have existed for several years, 
the patient retaining sufiicient strength to labor, and not considering 
himself much of an invalid. On inquiry, it appears that haemoptysis 
has formerly occurred. A careful examination reveals the physical 
sign of disease at the summit on both sides. Tuberculosis is suffi- 
ciently established, and the progress of the case confirms the diag- 
nosis. This is a transcript of the leading circumstances of a case 
which actually occurred. 

Dilatation of the bronchise, as has been seen in treating of this 
lesion, may present the physical signs characteristic both of tuber- 
culous solidification and excavation. The diagnostic points have 
been fully considered. A simple enumeration of the more important 
of them will here suffice. The significant symptoms of tuberculosis 
are wanting, viz., haemoptysis, notable and progressive emaciation, night 
perspirations. The situation of the physical signs is less uniformly 



500 DISEASES OF THE RESPIRATORY ORGANS. 

at the summit of the chest. The percussion-dulness is not propor- 
tionate to the intensity of the bronchial respiration ; and if cavernous 
signs exist, they may be accompanied with little or no evidence of 
solidification surrounding the excavation. These are negative points, 
which may warrant the exclusion of tuberculous disease. Instances, 
however, are occasionally met with in which the differential diagnosis 
is difficult, and, indeed, cannot be made with positiveness. But the 
infrequency of cases involving doubt is such, that occasions for em- 
barrassment belong among the extraordinary incidents of clinical 
experience. The period of life when dilatation of the bronchise is 
found to exist sufficiently to simulate phthisis, is usually more ad- 
vanced than that at which tuberculous disease is most apt to be deve- 
loped. The age is therefore entitled to some weight in the diagnosis. 

It will seldom be a matter of question, whether an existing affec- 
tion be tuberculosis or pulmonary apoplexy. Yet I speak from per- 
sonal experience when I say, that to the young auscultator the inquiry 
may arise under the following circumstances. A person believing 
himself to be in good health is attacked with copious haemoptysis. 
The hemorrhage is not preceded by cough or any apparent pulmonary 
symptoms. For some months afterward the cough and expectora- 
tion are slight. There are no chills, pleuritic pains, nor any of the 
symptoms significant of phthisis. The average weight is retained. 
The respirations, when the patient is tranquil, number only 16. The 
aspect is not morbid ; the appetite and digestion good. On physical 
exploration, marked dulness is found over the upper and middle thirds 
on the right side ; the respiratory sound scarcely appreciable, with 
no sound of expiration, and vocal resonance moderately greater than 
on the opposite side. On the left side the percussion-resonance is 
clear and vesicular ; the respiratory murmur appearing normal, 
except the intensity is increased. The parents are both living and 
well. Moreover, the patient, who is a young physician, expresses 
the belief that the dulness on the right side is less than heretofore. 
These are the prominent points noted in the history of a case, in 
which, I confess, I was disposed to think sanguineous infiltration had 
occurred. On examination a few months afterward, the evidence of 
tuberculous disease was ample, and the patient died with undoubted 
phthisis. 

The diagnosis of pulmonary apoplexy is confessedly obscure ; but 
of this it will be more appropriate to speak in connection with that 
affection, which will be noticed in the next chapter. I will only re- 
mark here, that it probably is a result in the majority of cases, of 



PULMONARY TUBERCULOSIS. 501 

obstruction incident to heart-disease. This furnishes an important 
diagnostic point, which is the more significant, because pulmonary 
tuberculosis is rarely associated with cardiac lesions involving obstruc- 
tion. Tuberculosis and pulmonary apoplexy may coexist. I have 
known the latter to supervene upon the former, and destroy life so 
speedily, that a coroner's inquest was held to determine the cause of 
death. 

In the foregoing remarks under the head of diagnosis, it has been 
assumed all along that tuberculous disease commences always at or 
near the apex of the lung on one side, the other side subsequently 
becoming affected, as a rule ; and that the deposit more or less gra- 
dually extends from the superior portion . downward. Exceptions to 
the laws of pulmonary tuberculosis just stated occasionally occur. 
The deposit in a very small proportion of instances commences at or 
near the base of the lung, and extends upward, thus completely 
reversing the usual course of the disease. Dr. H. I. Bowditch of 
Boston, has lately reported eight cases of this kind, in a paper to 
which reference has been already made in the chapter on Pneumonitis. 
Dr. Bowditch estimates that these exceptional instances are liable to 
occur in a ratio of 1 to 150 or 200 cases.^ The instances observed 
by him were characterized by a well-marked crepitant rale, behind, 
over the lower lobe, persisting for weeks or months, followed by the 
physical signs of solidification, the disease finally extending to the 
upper lobe, affecting both sides, and advancing to the formation 
of cavities, as in the ordinary form of tuberculosis. The sympto- 
matic phenomena in these cases did not present any material varia- 
tion from those usually observed in phthisis. The diagnosis involves 
discrimination from pneumonitis. The physical signs are common to 
the two afi'ections, but with this essential difference : in the tubercu- 
lous afi'ection.the crepitant rale persisted for weeks and months, soli- 
dification being slowly induced. Limiting the attention to the phy- 
sical phenomena, this course bears but a remote analogy to pneumo- 
nitis. Moreover, the history and symptoms embrace points which 
mark the distinction. Symptomatic fever was absent in the majority 
of the cases after they came under medical cognizance, and the local 
indications of inflammation. The patients did not lose their strength 
except gradually in the progress of the disease, as in ordinary phthi- 
sis. They were able for a certain period to be up and out of doors. 
Certain of the symptoms highly significant of tuberculosis were noted, 

' Louis found tuberculous disease confined to the lower lobe in 2 of 123 cases. 



502 DISEASES OF THE EESPIRATORY ORaANS. 

viz., ragged opaque sputa, and in two cases haemoptysis. The occa- 
sional deposition of tubercle primarily at the base of the lung, en- 
forces the importance of not limiting exploration for the physical 
evidence of the disease to the summit of the chest. When the laws 
regulating the seat and progress of the deposit are thus reversed, 
the diagnosis may require some delay and repeated examinations. 
The physical taken in connection with the symptomatic phenomena 
will at length furnish sufficient data for a correct opinion. 

SUMMARY OF THE PHYSICAL SIGNS BELONGING TO PULMONARY 
TUBERCULOSIS. 

Diminished vesicular resonance on percussion at the summit of the 
chest, varying in degree from slight dulness to a near approach to 
flatness ; present on one or on both sides, but in the latter case more 
marked on one side ; the dulness, in general, proportionate to the 
abundance of the tuberculous deposit; increased sonorousness occa- 
sionally observed at the summit of the left side, due to transmitted 
gastric resonance, the sound tympanitic in quality and high in pitch ; 
the vesicular, frequently replaced by a tympanitic sound on either 
side, when the sonorousness is not increased, constituting tympanitic 
dulness. 

An increased sense of resistance in proportion to the amount of 
crude tubercle. 

A tympanitic resonance over a circumscribed space at the summit, 
present and absent at different examinations, in some cases presenting 
an amphoric and the cracked-metal intonation, constituting the evi- 
dence afforded by percussion of the existence and situation of tubercu- 
lous excavations. 

On auscultation, the broncho-vesicular and the bronchial respira- 
tion, the latter denoting tuberculous solidification. Frequently, 
with these modifications, diminished intensity of the respiratory 
sounds ; occasionally suppression of all respiratory sound ; interrupted 
or jerking respiration. Exaggerated vesicular murmur on the side, 
either healthy or least affected ; the crepitant, sub-crepitant, sibilant, 
or sonorous, mucous, and crackling, or crumpling rales, occurring as 
contingent signs, their significance dependent on their being found 
within a circumscribed area at the summit of the chest ; abnormal 
transmission of the heart-sounds, especially at the right summit ; 
increased vocal resonance when situated on the left side at the 



ACUTE PHTHISIS. 503 

summit ; an acute and more or less intense souffle, or bellows' sound, 
accompanying whispered words, especially if present on the left side ; 
bronchophony, and occasionally transmission of speech, complete or 
incomplete, over tuberculous solidification ; a friction-sound, limited 
to the summit of the chest. 

The cavernous respiration, occasionally observed, alternating with 
suppression, or gurgling, occasionally amphoric, and, very infre- 
quently, pectoriloquy, constituting the evidence, afforded by auscul- 
tating the respiration, of the existence and situation of excavations ; 
the characters of the cavernous and bronchial modifications of the 
respiration, sometimes combined (broncho-cavernous respiration) ; 
splashing, an impulse, seen and felt, existing within a circumscribed 
space at the summit — signs of cavities furnished by the act of cough- 
ing ; occasionally, when the cavity is very large, metallic tinkling. 

By inspection, flattening, or depression at the summit, either con- 
fined to one side, or more marked on one side than on the other ; the 
clavicle generally more prominent, but occasionally receding with 
the ribs ; diminished expansibility with the act of inspiration ; the 
range of motion found to be lessened, as well as size of the chest at 
the summit, by mensuration. 

Disparity at the summit of the chest in vocal fremitus, provided it 
be found to be greater on the left side. 

A splashing succussion-sound in some cases of very large excava- 
tion. 

Acute Phthisis. 

Pulmonary tuberculosis in the vast majority of instances is emi- 
nently a chronic disease. It rarely terminates under several months, 
and is frequently protracted for a series of years. Occasionally, 
however, the disease runs a rapid career. In a case observed by- 
Louis, it passed through its different stages, and ended fatally in a 
month after the occurrence of the first symptoms.* A case has fallen 
under my observation, in which death took place in seventeen days, 
dating from an haemoptysis which was immediately followed by grave 
pulmonary symptoms, the patient at the time of the hemorrhage being 
apparently in excellent health. A latent tuberculous deposit, however, 
probably existed previously. A slight haemoptysis had occurred 
several months before, and, meanwhile, there existed a little hacking 

* Valleix, op. cit. 



SIN: BiSEAEi^ :j :zi : z ^ :::..:;: r ; : :^Asrs. 

eoD^i, iviiiL : ;: : -z-r.- :'-..:.. -r:.z..i.z ': i:: :; esdle llie least 



pa]iapsiMi<: -- --- '-- -i-'. :::i ;: :i^ disease, 

a® '?e"-"?T:iii~ r '^ _ ; __ :^ r 1. ' - " i: ■• " ' i: : : = : t i_ ' _ .^i ' . ~ ^ ^ ; : : , In the 



tiim in ^eat mnnbesra vH graj & 
rewwajping isfdated/or cwalcawang. 
tralioa. Eestiidted to tiie eond: 
(pMkime ^ 



The graiular dcf : : " i 7 

Jbodi sidesB, in about .; 

plaee iMtsmt sc^kning and excsbT _ 

Hie djagnnajs of llie form &i dbeaae ; 7 

be deiioniinatediismie in di^Tii t: - :* 1^ - 

phfbiaia), is nolfc anaHended 7 5 - I _ 7 

le^ dislinettive fban in ordi:: 7 . ^ _ : _ 5 

being anrailaneoadtj and in ^ -:. 

nailEed f^arify in fbe per: ~ - ^- 

Iffbegnumlatinis remain 15 _ 7 1 e 

dnlngsgB is nofe prodneed. A _ _ 

noniein odier tban aie a^H^i T ^ : ; .: 

and bidibling soonds, in£iB^> T _ !_ 1 

sigDS of tnbexenloas aoiidific : ~ . . 

dio^MMij, and fcemifiiif;, mz- - _ I_ _ „ _: _ _5 

atlien£ns Ibe progre^ of t^ 7 1 : -i It i^r 

"•- T ::_-. tbe poise becoEiiz ^ .-. ' ":-l Lr'::i" :":-■_ : :iT 

5:;:: : .^^-masBoiairjfratz. -- 'r :i :. t: ^r :i -..r :\ t :i:- 

:: :_T . 7^ .. -::3a.wiib orw::„ ; " : :. 7 : 1 ":_. '7_- 77 ; : : -:. .1^ 

y. :_ ^ : „ : ; : '. : 7 ' :zl or dtj"5': :^ 7 \:z.'zz^ : : - :_ 7 : : Wsud 



1 



ACUTE PHTHISIS. 505 

chest, which are rarely severe ; cough more or less violent, dry, or 
accompanied by small expectoration which is sometimes slightly 
bloody ; occasionally diarrhoea. Owing to the rapid march of the 
disease, emaciation is a symptom much less marked than in ordinary 
tuberculosis. 

The differential diagnosis from other affections offers an exception 
to the rule stated, with reference to chronic tuberculosis, viz., that it 
turns mainly on the presence or absence of the positive characters of 
the tubercular disease. The positive characters of acute phthisis 
being less distinctive, in discriminating, clinically, between this and 
other affections, the latter are to be excluded by the absence of their 
diagnostic traits. 

The frequency of the respirations, dyspnoea, lividity, and rapidity 
of the circulation, might lead to a suspicion of disease of heart. The 
latter is to be excluded by the absence of the positive physical signs 
which denote its existence when present. 

Pneumonitis is excluded by the absence of signs denoting solidifi- 
cation extending over an entire lobe (in the adult), which is oftener 
the lower lobe ; by the physical phenomena showing the development 
of disease simultaneously on both sides ; the affection not travelling 
successively from lobe to lobe, and the upper portion of the lung 
being generally found to be especially affected. 

The existence of simple acute bronchitis, either of the ordinary or 
capillary form, is disproved by a disparity, in a certain proportion of 
cases, existing between the two sides in the resonance on percussion ; 
by the bronchial rales being less marked, and most manifested at the 
summit of the chest, instead of over the inferior posterior surface ; by 
a less abundant muco-purulent expectoration ; by the dyspnoea and 
increased frequency of respiration being, on the one hand, much 
greater than in ordinary acute bronchitis, and, on the other hand, 
less marked, the immediate danger less imminent, and the career of 
the disease longer than in acute general capillary bronchitis. 

The affection with which acute phthisis is most liable to be con- 
founded is typhoid fever. The latter affection is to be excluded by the 
absence of its characteristic abdominal symptoms, viz., tympanites, 
iliac tenderness, gurgling, and diarrhoea. Diarrhoea, however, it is to 
be borne in mind, is occasionally a prominent symptom during the 
latter period of acute phthisis, dependent on a tuberculous complication 
of the intestines. The presence of the typhoid eruption, if well marked, 
settles the diagnosis ; but the absence of the eruption is not proof 



506 DISEASES OF THE RESPIEATORY ORGANS. 

that the disease is not typhoid fever. The accelerated breathing and 
dyspnoea of acute phthisis do not belong to the natural history of 
typhoid fever, except when it becomes complicated with pneumonitis, 
and this complication is ascertained by means of physical signs. 
Even with a pneumonic complication, it is extremely rare for the 
respiration to become embarrassed to the extent which obtains in 
cases of acute phthisis. 

Typhoid fever is farther distinguished by being preceded by a pro- 
dromic period, by the earlier occurrence of the peculiar mental con- 
dition, as well as its greater prominence, and by the pulmonary 
symptoms, when present, being developed secondarily, at a period 
more or less remote from the date of the attack. It is chiefly when 
cases first come under observation at a late period in the disease, and 
it is impossible to obtain an account of the previous history from the 
patient, or others, that the diflferential diagnosis is attended with real 
difficulty. • 

Retrospective Diagnosis of Tuberculosis. 

The frequency with which small cretaceous formations, indurations, 
and puckerings, are found after death in the bodies of persons who 
have not died from pulmonary disease, renders it probable that a 
small tuberculous deposit often takes place and is arrested, in conse- 
quence either of a limitation inherent in the disease, or from certain 
influences brought to bear upon it, without advancing through its 
usual changes, and not producing any serious injury of the pulmonary 
organs.' Clinical observations confirm the correctness of the suppo- 
sition that an arrest of tuberculosis may take place, the deposit ceas- 
ing, the symptomatic evidences of the disease, if present, disappearing, 
and the patient recovering perfect health. In making examinations 
of the healthy chest, I have met with instances in which a slight 
disparity was found in the percussion and respiratory sound at the 
summit, not attributable to any want of symmetrical conformation, 
and not in accordance with the laws regulating the normal variations 
between the two sides. On inquiry, it appeared to be a rational con- 
clusion, that at a former period, these persons had been affected with 
a small tuberculous deposit. The circumstances which rendered this 

^ Dr. W. T. Gairdner suggests that the indurations frequently found in the lungs and 
attributed to tuberculous deposit, are frequently due to collapse of lobules from bron- 
chial obstruction. See Art. in Brit, and For. Med. Chir. Rev., already referred to. 



X 



RETEOSPECTIVE DIAGNOSIS OF TUBERCULOSIS. 507 

supposition probable, were certain significant symptoms, such as per- 
sisting cough, loss of weight, and in one instance haemoptysis, which 
had existed years before, continued for a time, and in the intermediate 
period the persons had been free from any obvious indications of a 
pulmonary affection. The physical phenomena in these cases consisted 
in dulness at the left summit, with feebleness and diminished vesicu- 
larity of the respiratory sound. These signs, if slight, in view of the 
normal disparity frequently existing between the two sides, possess 
much greater significance as evidence of past, as well as present 
tuberculous disease, when they are found at the summit of the left 
side. 

I have also preserved notes of examinations in several cases in 
which the symptoms and physical signs were considered as indicating 
unequivocally the existence of tuberculosis, and the patients afterward 
recovered excellent health, the pulmonary symptoms gradually dis- 
appearing. A captious reader might suggest that in some of these 
instances an error of diagnosis was committed. I am far from pro- 
fessing not to have committed such errors, but in the cases to which 
I refer, the evidence was quite positive, and of a character not easily 
mistaken. In some of these cases I have examined the chest after 
recovery, and found a persisting disparity between the two sides, con- 
sisting of comparative dulness on percussion, with relative feebleness, 
and an approach to the characters of the broncho-vesicular respira- 
tion. 

Arrested tuberculosis, therefore, is to be included among the con- 
ditions giving rise to a permanent disturbance of the symmetry of the 
chest as respects the phenomena furnished by physical exploration, 
and not indicating present disease. In view of this fact, it is im- 
portant, in examinations of the chest which disclose a slight disparity 
at the summit, more especially if the abnormal modifications are 
situated on the left side, to inquire into the previous history of the 
patient, in order to ascertain whether at some former period there did 
not exist symptoms rendering it probable that there was at that time 
a tuberculous deposit. 

But it is sufficiently established that recovery from tuberculosis 
may take place after an abundant deposit, and when the -disease has 
advanced to the formation of cavities of considerable size. Gradual 
contraction and cicatrization of excavations may take place, or they 
may remain in a stationary and innocuous condition ; the tuberculous 
matter may be quiescent, and probably its complete absorption is not. 



508 DISEASES or THE RESPIRATORY ORGANS. 

as lias been supposed, impossible.^ Instances exemplifying recovery 
from tuberculosis, even when considerably advanced, it may reasona- 
bly be hoped, will be of more frequent occurrence than heretofore, 
in consequence of improved views of the pathology and treatment of 
the disease. I am acquainted with two persons who have been af- 
fected with tuberculosis, as shown by the previous history, one for 
21, and the other for 28 years. Both have had repeated hemor- 
rhages, with cough and expectoration, during the periods named, 
which still continue. But yet both enjoy a tolerable amount of 
health. It is a curious fact with respect to these cases, that the 
patients are husband and wife. The husband was tuberculous at the 
time of his marriage ; the affection in the case of the wife became 
developed subsequently. It is worthy of being added, that in both 
cases the disease has been allowed to pursue its course with very little 
medical interference, and both have steadily continued to perform 
the active duties of life, the husband as a merchant, and the wife as 
an active superintendent of household affairs. 

An illustration of recovery from an abundant tuberculous deposit, 
and of the subsequent physical signs, is afforded by a case in which I 
examined the chest, noting the results, five years ago, and an oppor- 
tunity presented of repeating the examination a few months since. At 
the first examination, December, 1850, the patient, a female, aged 19, 
had been affected with the disease for two years, dating from the occur- 
rence of haemoptysis, which was shortly followed by cough and ex- 
pectoration. There existed marked dulness at the left summit in 
front and behind, with diminished expansibility, a feeble bronchial 
respiration, and weak bronchophony. At the summit of the right side 
the respiration was broncho-vesicular. The patient after this exami- 
nation passed from under my observation, and I did not again see 
her till I was requested to decide on the propriety of her being ad- 
mitted as a novice into the order of the Sisters of Charity. Her 
aspect was not morbid. She had a fine complexion, and considered 
herself well and abundantly able to perform the duties of the religi- 
ous vocation to which she aspired. She had, however, a slight cough 

^ To consider the processes hy which recovery is effected, is not, of course, appro- 
priate in this work. For this the reader is referred to late treatises on tuberculosis, and 
on the subject of morbid anatomy. I would particularly recommend the late essay on 
tuberculosis by Prof J. Hughes Bennett of Edinburgh, for evidence and illustrations of 
recovery from phthisis. And I avail myself of this opporUmity to express my obliga- 
tions to Prof. B. for the privilege, while in Edinburgh, in 1854, of examining the speci- 
mens which are figured in his work. 



'BRONCHIA^. PHTHISIS. 509 

and expectoration chiefly occurring in the morning. The upper third 
of the left side was notably depressed, the clavicle having also some- 
what receded. Dulness on percussion was marked in this situation. The 
respiration was feeble on the left side, without obvious disparity in 
pitch or quality. The difference in intensity was marked. A pro- 
longed expiration existed on the left side, the pitch being obscured 
by a sibilant rale ; on the right side an expiratory sound scarcely ap- 
preciable. The vocal resonance was notably greater on the left side. 
The subject of arrested tuberculosis and recovery from the disease 
is one of very great interest and importance, in its relations to patho- 
logical inquiries and the management of the disease. It is foreign 
to the objects of this work to consider it in these aspects. The main 
purpose of these few remarks, as implied in the heading, has been to 
illustrate the application of physical exploration in supplying data 
for a retrospective diagnosis of the disease. 



TUBEECULOSIS OF THE BRONCHIAL GlANDS — BRONCHIAL PHTHISIS. 

In a large proportion of the cases of pulmonary tuberculosis, the 
tuberculous affection extends to the bronchial glands. Enlargement of 
these glands belongs among the varied anatomical conditions repre- 
sented by the physical phenomena pertaining to the disease, not, how- 
ever, giving rise to any special signs by which the existence of this com- 
plication can be determined during life. But the tuberculosis may be 
limited to these glands. They may be the seat of a tuberculous deposit 
involving a considerable increase in size ; and by means of processes 
similar to those which take place in connection with tubercles deposited 
in the pulmonary structure, cavities may be produced, communicating 
with the bronchia, occasionally opening into the oesophagus, and some- 
times into the pleural cavity. The glands primarily affected are those 
situated near the bronchi ; thence the disease extends to the glands 
imbedded in the lungs, in the direction of the bronchial subdivisions, 
and also to those in the neighborhood of the pericardium, the oeso- 
phagus, and the large vessels in the anterior mediastinum.^ 

In all these situations the bronchial glands are frequently affected 
as a complication of ordinary pulmonary tuberculosis, especially in 
children. It is only when they are the seat of a tuberculous deposit 
exclusive of pulmonary tubercles, that the disease is properly distin- 

' Hasse. 



510 DISEASES OF THE RESPIRATORY ORGANS. 

guished as hronchial phthisis. Tuberculosis limited to the bronchial 
glands is a disease 23eculiar to childhood. With this restriction to 
early life, it is a rare form of disease, for, if not preceded, it is apt to 
be followed, by pulmonary tubercles. In a certain proportion of 
the cases of true bronchial phthisis recovery takes place. This pro- 
portion would be larger than it is, except for the liability during the 
course of the disease to the occurrence of ordinary pulmonary tuber- 
culosis. 

The diagnosis of bronchial phthisis is desirable, especially in view 
of the fact that the chances of recovery are more than in ordinary 
tuberculosis ; and, on the other hand, it is important to distinguish it 
from simple bronchitis or'pertussis, with which it may be confounded, 
these affections being attended comparatively with much less danger. 
In either case the discrimination is attended with difiSculty, in part 
from the obstacles in the way of a satisfactory exploration of the 
chest in children, and partly because physical signs distinctive of the 
disease are often wanting. The difficulty of discrimination relates 
more particularly to the differential diagnosis from ordinary tubercu- 
losis, with which it is so frequently associated. 

The disease coexists with either persisting or recurring attacks of 
bronchitis ; the symptoms and signs of the latter affection are there- 
fore likely to be present. The cough is apt to assume a paroxysmal 
character, resembling that of hooping-cough. (Edema of the face and 
swelling of the veins of the neck are events occasionally occurring, 
arising from pressure of the bronchial glands on the vena cava. The 
respiration is more or less hurried. The loss of flesh is marked, but 
in this respect, and as regards other symptoms, during the course of 
the disease remarkable fluctuations are observed.^ The lymphatic 
glands of the neck are frequently affected. 

As regards physical signs, feebleness or suppression of the respira- 
tory sound on one side is an occasional incidental effect due to pres- 
sure of an enlarged gland on one of the bronchi or its larger subdivi- 
sions. Dulness on percussion may be apparent in the interscapular 
regions. The bronchial respiration at or near the situations where it 
is normally sought for, viz., in the interscapular space behind, and in 
the neighborhood of the sterno-clavicular junction in front, may be 
abnormally exaggerated. Mucous rales are more abundant, and pos- 
sibly gurgling may be observed in the same vicinity. These signs, 
provided pulmonary tuberculosis be excluded by the absence of 

1 Vide West on Diseases of Children, Am. Ed. 1854, p. 287. 



BRONCHIAL PHTHISIS. 511 

the physical evidence of solidification over the chest elsewhere 
than at the parts just named, taken in connection with the ra- 
tional evidence of phthisis, viz., persisting cough and emaciation 
and sometimes perspirations, constitute the data for the diagnosis. 
Assuming all these data to be available, the diagnosis may be made 
with much confidence. Even if the positive signs are wanting, if 
the history and symptoms show that the disease involves something 
more than bronchitis, and render the existence of phthisis alto- 
gether probable, provided the physical signs of pulmonary tubercu- 
losis are also absent, reasoning by exclusion there is good ground for 
the opinion that the patient is affected with bronchial phthisis. 
(Edema of the face and swelling of the veins of the neck constitute, 
in connection with other evidence, a significant indication. Enlarge- 
ment of the lymphatic glands of the neck is also entitled to weight 
in the diagnosis. 



CHAPTER YI. 

PTJL:M0XARY CEDEMA— GAXGEEXE of the LUXCtS— pulmoxaey 
APOPLEXY— CAXCER OF THE LUXOS— CAXCER EN' THE AJEDI- 
ASTIXUM. 

The affections named in the heading of this chapter will complete 
the list of those which in their anatomical seat have relation to the 
air-cells or the pulmonary parenchyma. The order in which they are 
enumerated coiTesponds to the relative frequency of their occurrence. 
Collectively they claim a much less extended consideration than has 
been bestowed on each of the affections belonging in the same group 
which have constituted the subjects of the three preceding chapters. 



Pulmonary (Ede.ma. 

The anatomical characters of oedema of the lungs are due to serous 
effusion taking place, according to Rokitansky, primarily and chiefly 
within the air-cells, the infiltration, however, extending to the inter- 
vesicular areolar tissue. The volume of the affected lung is slightly 
augmented ; it does not collapse or crepitate on pressui-e. The yel- 
lowish limpid fluid which oozes in abundance on section, is usually 
slightly frothy, showing the access of a small quantity of air to the 
cells ; the texture is solid, resisting, non-elastic, pitting on pressure 
as in subcutaneous oedema. 

Pulmonary oedema, more or less circumscribed, is found very fre- 
quently as an anatomical condition incidental to nearly all affec- 
tions of the lungs which prove fatal. It occurs as a consequence 
of the hypostatic congestion taking place in the latter part of fevers 
and various diseases. It may even be a post-mortem event. De- 
veloped in conjunction with other pulmonary affections, the phe- 
nomena to which it gives rise are so interwoven with those incident 
to the coexisting morbid conditions, that their recognition is imprac- 



PULMONARY '(EDEMA. 513 

ticable. It is only as an independent affection, i, e. disconnected 
from other pulmonary diseases, that it is of clinical importance in a 
diagnostic point of view. As a separate pulmonary disease it is 
always dependent on some anterior morbid condition. It arises 
secondarily in the course of organic diseases of the heart accompanied 
by mitral regurgitation or obstruction, and more rarely, from hyper- 
trophy affecting the right ventricle. It may also proceed from the 
condition of the blood which, at the same time, gives rise to dropsical 
effusions in other situations. Hence it is liable to occur in Bright's dis- 
ease. These pathological relations are important to be borne in mind 
with reference to the diagnosis. When the serous infiltration takes 
place rapidly and extensively, as has been sometimes observed, induc- 
ing death suddenly, it has been termed serous apoplexy of the lungs. 
Developed in the course of heart-disease or general dropsy, it is not 
always either limited to or most marked in the inferior and posterior 
portions of the lungs on both sides, which is the case when it depends 
on hypostatic congestion. It may exist on one side only, and be con- 
fined to the superior lobe. In a case which recently came under 
my observation, the oedema occurring in connection with hydro-peri- 
cardium, and softening of the heart, moderate serous effusion existing 
also in the pleura and peritoneum, the upper lobe of the left lung was 
alone affected. 

Physical Signs. — (Edema sufficient in amount and in the extent 
of lung affected to constitute an important pathological condition, is 
accompanied by marked dulness on percussion. According to Skoda, 
the tympanitic quality of sound may be elicited over lung made 
dense by serous infiltration, as in cases of solidification from inflam- 
matory exudation or tubercle. The resistance of the thoracic wall 
over the oedematous lung is notably increased. 

Owing to the presence of serous liquid in the air-cells and minute 
bronchial tubes, a sub-crepitant rale is discovered on auscultation. 
Occasionally, the rale presents all the characters distinctive of the 
true crepitant, viz., finer than the sub-crepitant, dry, equal, and 
limited to the inspiratory act. Such instances must be extremely 
rare exceptions to the rule, that fine bubbling, or the sub-crepitant 
rale, belongs to this form of disease. 

The respiratory sound, when not obscured by the presence of rales, 
is found to present more or less of the characters of the broncho- 
vesicular, or the bronchial modifications. The bronchial respiration, 
however, is never so strongly marked in oedema as in cases of inflam- 

33 



514 DISEASES OF TUE RESPIRATORY ORGANS. 

matory or tuberculous solidification, and the high-pitched metallic 
quality frequently observed in connection with the latter morbid con- 
ditions, does not belong to this affection. Great feebleness, and sup- 
pression of the respiratory sound, are oftener incident to oedema than 
to pneumonitis and tuberculosis. 

The vocal resonance may or may not be increased. The same re- 
mark is applicable to the vocal fremitus. As regards the souffle with 
whispered words, I am unable to offer the results of any observations. 

Inspection furnishes negative results. 

Diagnosis. — The symptoms belonging to pulmonary oedema offer 
nothing diagnostic. With more or less cough, and the expectoration 
of a serous or muco-serous fluid, the respiratory function is compro- 
mised in proportion to the degree and extent of the oedema. These 
are the only symptoms referable to the m.orbid condition of the lungs ; 
and since the affection occurs as a complication of other diseases, 
symptoms due to the latter are intermingled. Thus, in the larger 
proportion of cases, the symptomatic phenomena arising from disease 
of heart are present, and, in other cases, hydrothorax, together with 
effusions into other serous cavities, anasarca, &c., dependent on disease 
of the kidneys. 

The positive signs, as has been seen, are dulness on percussion, and 
a sub-crepitant rale. These signs being present over a portion of the 
chest, on one or both sides, with or without the characters of the 
broncho-vesicular or the bronchial respiration, exaggerated vocal 
resonance and fremitus, and accompanied by more or less acceleration 
and labor of the respiration, the diagnosis involves, first, their asso- 
ciation with diseases in connection with which oedema is known to 
occur ; and, second, the exclusion of other affections in which solidifi- 
cation of lung takes place, more especially pneumonitis, and the hy- 
postatic congestion, or pseudo-pneumonitis, which is incident to the 
course of fevers, and some other diseases, particularly toward the 
close of life. If the above-mentioned physical signs become de- 
veloped in the course of an organic affection of the heart, especially 
if attended with obstruction to the pulmonary circulation, such as is 
incident to diseases affecting the mitral orifice, or in conjunction with 
general dropsy, the occurrence of oedema is established with con- 
siderable certainty, provided we are satisfied of the non-existence of 
the affections to be excluded. The existence of ordinary pneumonitis 
is rendered improbable by the absence of pain, of the characteristic 



GANGRENE OF THE LUNGS. 515 

sputa, of febrile movement, and the physical signs denoting solidifi- 
cation of lung from the deposit of inflammatory exudation, viz., a 
well-marked and intense bronchial respiration, bronchophony, and the 
true crepitant rale. The latter sign, however, it is to be borne in 
mind, may be observed in cases of oedema. Hypostatic congestion, 
as already stated, involves oedema as an anatomical element. To 
make the distinction clinically under the circumstances which attend 
the development of hypostatic congestion, is unimportant. (Edema 
is most apt to affect the inferior and posterior portions of both lungs 
simultaneously, but this rule is invariable with respect to hypostatic 
congestion. The latter condition is, therefore, of course excluded 
whenever the phenomena denoting oedema are manifested at the supe- 
rior and anterior portion of the chest. 

"With hydrothorax, oedema need not be confounded. The change 
of level of the liquid with the different positions of the patient, suffice 
to indicate the former. But the two affections may coexist. To de- 
termine the fact of this coexistence may not be easy. The presence 
of the sub-crepitant rale, and the modifications of the respiratory 
sound due to solidification, viz., the broncho-vesicular or bronchial 
respiration, superadded to the physical evidence of liquid in the 
pleura, taken in connection with the existence of general dropsy, may 
enable the diagnostician to make out this combination. Practically, 
however, success is not very important. 

SUMMARY OF PHYSICAL SIGNS BELONGING TO PULMONARY (EDEMA. 

Absence of vesicular resonance en percussion, with increased 
parietal resistance ; sub-crepitant, and, occasionally, the crepitant 
rale ; broncho-vesicular or the bronchial respiration, never intense or 
metallic ; absence of respiratory sound; increased vocal resonance 
and fremitus uncertain, and rarely, if ever, present in a marked 
degree. 

Gangrene of the Lungs. 

Since the time of Laennec, writers have considered gangrene of 
the lungs as divisible into two forms, viz., diffuse and circumscribed. 
In diffuse gangrene, a considerable extent of lung is affected, gene- 
rally, the whole or the greater part of a lobe, and the boundaries 
of the gangrenous portion are not sharply defined. Both varieties 



516 DISEA5ZS J IZZ : Z PIRATOBY OJLGAISS. 

are exceeding! j rare, but of the cases that oecnr, those of the difiose 
form are vastly less frequent. 

Cir:"" scribed gangrene is more limited in extent^ and a well-de- 
rr- - L. T ; f demarcation separates the affected part from the adjacent 
pulmonary stractnre. The gangrenous p:i:::i. vin^s in size from 
that of a bean to a hen's egg. A single p : : :: : ii : : 7 nay be affected, 
or the disease may attack several distinci ; : :. I. r gangrene leads 
to sloughing, as in other situations. The decomposed lung-substance, 
reduced to a dark, greenish, fetid, diffluent mass, is evacuated generally 
through the bronchial tubes, but occasionally into the pleural cavity. 
Two instances of the latter have fallen under my observation. It has 
been known to find its way into the oesophagus, and into the r eri- 
toneal cavity. After the evacuation has taken place, an escavi::::: 
remains, proportionate in size to the extent of the gangre:ir. I.1 c 
certain ratio of cases, cicatrization takes place, and a comr r : r 
is effected ; or, if the disease do not end fatally, a cavity nc : t_^ : l 
for an indefinite period. Dr. Gerhard has reported a case in which 
an excavation was found post-martemy nine years after the date of 
tiie aisease. 

The anatomical conditions which are represented by physical signs 
are, in the first place, solidification of the pulmonary structure, until 
the sloughing of the affected portion of lung is accomplished. The 
extent of the solidification will at least be equal to the size of the 
gangrenous portion or portions. But it is often more extensive, for, 
in a certain proportion of cases, the gangrene occurs in the course of 
pneumonitis, and when not preceded by pneumonitis, inflammatory 
exudation, and oedema, taking place secondarily, extend to a greater 
or less distance around the eschar. A cavity, left by the removal of 
the decomposed portion of lung, constitutes a second anatomical con- 
dition. The occurrence of bronchitis, affecting the tubes in proximity 
to the gangrene, and the presence of liquid in these tubes, also give 
rise to physical signs. 

Circumscribed gangrene is most apt to occur in the inferior lobes 
oftener situated near the surface, but occasionally deeply seat^ ; on 
the other hand, diffiose gangrene attacks by preference the upper 
lobes. 

P'^ i ' ■-■^-''-^- — The physical signs belonging to gangrene of the 
Imigs are divisible into 1st, those ttIiI r^T resent the condition of 
solidification prior to the separation ani rei::oval of the decomposed 



GANGRENE OF THE LUNGS. 517 

pulmonary substance ; 2d, those due to the circumscribed bronchitis 
incidental to the disease, and to the presence of liquid in the bron- 
chial tubes ; and 3d, those distinctive of an excavation. Inasmuch 
as the diagnosis of the affection, as will be seen presently, is rarely 
made prior to the appearance of the gangrenous matter in the expec- 
toration, and, from the insidious manner in which the affection is deve- 
loped, examinations of the chest often being omitted until the event 
just mentioned occurs, the phenomena characteristic of this period are 
determined infer en tially, and from isolated cases which have been 
reported. Deductions based on an analysis of recorded cases are 
wanting, and this desideratum is the less readily supplied, owing to 
the great infrequency of the disease. Diminished vesicular reso- 
nance on percussion, or dulness more or less marked, will be propor- 
tioned to the size of the gangrenous portion of lung, its proximity 
to the surface, and the extent of superadded solidification from ante- 
cedent or consecutive inflammatory exudation, and oedema. When 
the gangrene occurs as a result of pneumonitis, the dulness will be 
likely to extend over the space occupied by an entire lobe. But if 
the gangrene be circumscribed, seated in the interior of a lobe, and 
the surrounding inflammatory exudation be limited, the pcrcussion- 
dulness will be confined to a comparatively small area, and may not 
be discovered even by the most careful exploration. If the affection 
supervene on an attack of pneumonitis, percussion furnishes no infor- 
mation which could warrant a suspicion that gangrene had taken 
place ; and if the affection be developed without being preceded by 
the evidence of inflammation of the lungs, the existence of dulness, 
if discoverable, will be often overlooked, or if discovered may not be 
attributed to gangrene. 

Auscultation in the part of the chest where dulness is found to 
exist, may furnish the respiratory and vocal signs of solidification, 
viz., more or less of the elements of the bronchial respiration, and 
increased vocal resonance, or bronchophony. Rationally considered 
it would be anticipated that during the decomposing processes lead- 
ing to softening and difiluence of the gangrenous mass, marked feeble- 
ness or extinction of respiratory sound would be a result often ob- 
served ; and, also, absence of reverberation and transmission of the 
voice. Bubbling rales, the mucous or sub-crepitant, are heard in the 
vicinity of the affected part, but they have been observed to extend 
over a larger space than that corresponding to the gangrenous por- 
tion of luncr. These rales are due to incidental bronchitis, and at a 



518 DISEASES OF THE RESPIRATORY ORGAXS. 

later period to liquid in the bronchial tubes derived from the excava- 
tion. It is possible that a true crepitant rale may be produced by 
the secondary inflammation of the pulmonary parenchyma surround- 
ing the circumscribed gangrenous portion. 

When an excavation has been produced and a bronchial communi- 
cation established, cavernous signs succeed those due to solidification. 
The cavernous respiration I have observed well marked in a gangre- 
nous excavation. Gurgling will be heard at variable periods, and 
sometimes pectoriloquy. 

Diagnosis. — The symptoms of gangrene of the lungs, before the 
matter of expectoration contains portions of the decomposed pulmo- 
nary substance, are not distinctive of the affection. In a certain 
proportion of cases pneumonitis precedes, and the symptoms, of 
course, are those of the latter affection. Exclusive of these cases, 
the symptomatic phenomena referable to the lungs are often vague. 
Cough, with expectoration, denoting bronchitis, may be present, and 
obscure pains in the chest, accompanied by febrile movement, marked 
prostration, and general malaise. The disease may be developed with- 
out any symptoms which direct attention to the chest. Gangrene of 
the lungs, in fact, is rarely a purely primary affection. It occurs in 
the course of fevers, in connection with epilepsy, cerebral affections 
involving insanity, the effects of intemperance, etc. Illustrations of 
the several pathological connections just mentioned have come under 
my observation. The disease is rarely suspected until it is declared 
by characters of the expectoration which are highly distinctive. 
A remarkable fetor of the expectoration is the most characteristic 
trait. The odor is of the peculiar kind called gangrenous, and is 
similar to that of other moist tissues undergoing decomposition, while 
in contact with living parts.' It is intense, rendering the atmosphere 
of the apartment frequently almost insupportable. It is generally 
perceptible in the patient's breath, but is much greater during acts 
of coughing, even when unaccompanied by expectoration, and, in some 
instances, is confined to the breath expired in coughing. The matter 
expectorated is at first of a dirty grayish or greenish color, resembling 
the diffluent decomposed substance of lung, found in the gangrenous 
parts after death, in cases in which its removal had not been accom- 
plished during life. Subsequently the expectoration becomes puru- 

* The odor is said by Louis and Grisolle to be stercoraceous. It has not appeared to 
me to have that character in the cases that have come under my observation. 



GANGRENE OT THE LUNGS. 519 

lent, and the fetor diminishes or may disappear. Even before the 
eschar has been removed, the fetor is sometimes observed to be inter- 
mittent, owing probably to the occurrence of transient obstructions of 
the bronchial tubes leading to the gangrenous mass. If perforation 
of the lung ensue, the fetor may diminish or cease. 

The diagnosis hinges on the distinctive characters pertaining to the 
breath and expectoration. Without these it would be impossible to 
determine the existence of gangrene. But a gangrenjous fetor is 
not alone sufficient to establish the diagnosis. This is an occasional 
symptom in bronchitis, in abscess following pneumonitis, in the caver- 
nous stage of tuberculosis, and in pneumo-hydrothorax. There are, 
however, certain circumstances connected with this symptom which 
render it almost pathognomonic of gangrene, and, on the other hand, 
with due attention to the points involved in the differential diagnosis 
from the several affections just named, the discrimination is rarely 
attended with much difficulty. If the expectoration suddenly assume 
a gangrenous fetor, at the same time becoming copious and present- 
ing the appearances characteristic of decomposed pulmonary sub- 
stance, the existence of gangrene is quite certain. The diagnosis is 
rendered still more positive if, prior to the irruption of this peculiar 
matter, the expectoration, as is sometimes the case, had been slight 
or altogether wanting. And it is established beyond question if, prior 
to the characteristic expectoration, the physical evidence of circum- 
scribed solidification had been ascertained, and subsequently the 
cavernous signs are discovered in the same locality. 

In the absence of the circumstances just mentioned, precision of 
diagnosis is to be based on the exclusion of the other affections in 
which fetor of the breath and the expectoration is an event of rare 
occurrence. 

Occurring in the course of bronchitis, and due, probably, to slough- 
ing of minute portions of the bronchial mucous membrane, it rarely, 
if ever, attains to the intensity common in pulmonary gangrene. It 
is always preceded and accompanied by the symptoms of bronchitis. 
It is developed less suddenly. The gangrenous matter is not apparent 
in the expectoration, or, at all events, is less abundant. The physical 
signs of solidification succeeded by those denoting an excavation are 
wanting. 

An abscess following pneumonitis offers the same physical signs 
as when gangrene results from that disease. The purulent matter 
expectorated in the former case is sometimes fetid, but it never has 



3^ 



SSF'imAX®mY OSe-ASS. 



jAat iisJDense i--..: -'_:;1 ; : ~.r: ::i :1^ latter ease. Use csjiteats of 
a pmgHiKiBL; ; ; r - i r rii: ^.-r dark^ samiois appearance 

'«]iid& dnar-i : - t . . : ^ - _ ^ irz z ^ ^— ^rcH : :Li Inng-snbstaiLee- Oil tkcae 
diaracters. :. : : : , ' r i witk niteiLse fetor^ succeeding an attack of 
pieoBi : : . - „_ - r : i i ' ; itIj predicated tiie Qpinioa tiiat gangreike 
liMtakr_ ■ :r 

TW I :;__;_ : _ . :: ^tanee "witluiL a tiiber- 

ealeoB : . - - . ^ , ^ . igrenous odor ta tke 

dp-:-' - "1 "7" T^ _:^r^c-. :•: :_ v "t wMeL obtains in 

it *ymptQniSy and 
ii .7 ntLy establish 



1^17 



_ 7 : 7 , rit lii«torv. 
tki3 stage : : ' 



if k 



. - -iliidi, as lias been scaced, niaT result from 
perfiHal^iHQ. : : : _ 7 ^ 7 . . in eomiifictkii witfe gangrsDe, is sxrEcientlj 
efidemeed bj plij^eal ^geiSy or ife is ea^j exeiaded bj die absence 
cf dieie^iis. 

Ii& some \erj laie instances a a^eifieial gaagrenoDs d#:iigh^ fimited 
in extent, raaj eaesifte int«» tbe plemral caTLtj witKont any eommiini- 
indi Ibe brandnal takes. Uliis nceaanred in a ease cmniDg 
nj cibsenatioiu' Undo* these dcrcsnisfeanees die diagnostic 
fetar c^ li&e brgadiL and expeetoEaticiiir maj be wanting. 
Aen&e plemids eientnating in pnenrao^drodMiiffax will be tlie resnlt^ 
and like pdor existence of gamgrene maj be an^ected; but to esta- 
bfiah tlie &et k ii^oesible. 

Gangreine of dte brags is t® be loolcedfiar ofitenest in duldreii^ next 
in adnh% and last in aged parsoos.* In four of fire caa^ occomng 
in dnldrQi wMdi wexe observed b j Boodel, a gangrenons a^eelicHk 
was seated in otli^r oigans as well as in tiie Imi^ and in two eases 
bodi lungs wae gangrenons. Hie coexistence of gmgreie in other 
is a pdint of soene in^ociance with lefein^ftee to the dsi^- 



WEMMI^K'-. 



riJi ZiiLC>5'©E?r<^ TO' ^A:?*"€f?ES3K o: 



Dolne^ on p^ieiEffliSQ^ la! 
postion be quite 






45. 



-t Serie^ 1S43. 



PULMONARY APOPLEXY. 521 

dulness on percussion ; inci'eased vocal resonance or bronchophony 
and fremitus, occasionally present ; mucous or sub-crepitant rales in 
the vicinity of the gangrenous portion ; possibly, a true crepitant 
rale ; subsequent to the occurrence of fetid expectoration, cavernous 
respiration, gurgling, and in some instances pectoriloquy. 



Pulmonary Apoplexy. ' 

Pulmonary apoplexy is a term used to designate extravasation of 
blood into the parenchyma of the lungs. The term is an unfortunate 
one, and for the sake of (Conformity to the nomenclature now in 
vogue, it is desirable to substitute the word pneumorrliagia. Extra- 
vasation may take place primarily, either into the air-cells, or into 
the interlobular and intervesicular areolar tissue, the blood in both 
cases, unless considerable laceration of the pulmonary structure be 
produced, coagulating and forming a consolidated mass, resembling, 
so far as density is concerned, a hepatized portion of lung. The 
space thus solidified varies in size, frequently being less than a cubic 
inch, and rarely exceeding four cubic inches. The extravasation 
may be confined to one spot, or it may occur at several isolated 
points. In some very rare instances it extends over a whole lobe, 
and even over the greater part of an entire lung. The limits of 
solidification are sometimes extended by oedema of the pulmonary 
substance surrounding the extravasation. Absorption of the effased 
blood is possible ; suppuration may ensue, and an excavation occupy 
the site of the apoplectic mass ; occasionally gangrene results. In 
some cases the extravasation occasions immediate and considerable 
laceration of the pulmonary structure, and a cavity is at once formed, 
containing fluid and coagulated blood, which has been known to be 
evacuated into the pleural sac. 

Apoplectic extravasations are most apt to occur in situations deeply 
seated in the pulmonary parenchyma, near the roots of the lungs, or 
in the posterior portion of the lower lobes. - 

The escape of blood into the bronchial tubes giving rise to haemop- 
tysis, occurs only when the extravasation takes place, or the blood 
gains access, into the air-cells. This constitutes the licemoptoic in- 
farctus of Laennec. In the larger proportion of cases of pulmonary 
apoplexy, hemorrhage manifested externally, in other words, hgemop- 
tysis, does not take place. 



522 DISEASES or izz kespiratort organs. 

PTiyncal Signs. — Dnlness on percnssion will be marked if tte 
portion of Inng solidified be of considerable size and sitnated near 
tKe pnlmonary superficies. But if it be small, or if tbe extrayasation 
occur at several points quite limited in extent, and disseminated, and 
imbedded beneath tke surface of the lung, dulness will be slight or 
not discoverable . 

The development of auscultatory phenomena involves the same 
conditions. If dulness be appreciable, or marked, the respiration 
over the site of the extravasation may be found to be suppressed, or 
to present more or less of the characters belonging to the broncho- 
Tesicnlar or the bronchial respiration. But if the size and situation 
of the consolidation are such that no alteration of the percussion- 
resonance is apparent, it is not probable that any distinct modification 
of the respiration will be discovered. Exaggerated vocal resonance 
and fremitus have been observed over an amount of consolidation of 
blood sufficient to give rise to dulness on percussion. 

Mucous and sub-crepitant ra-les are often heard in the vicinity of 
the extravasation. Occasionally the true crepitant rale is discovered 
over or near the situation of the soli«iified mass. 

If an excavation be produced, the cavernous signs mav be 'leveloped. 

Diagnosis. — Yery little was known respecting pulmonary extrava- 
sations prior to the researches of the illustrious discoverer of auscul- 
tation. Laennec supposed that they were always accompanied by 
haemoptysis. Subsequent observations have shown that this symptom 
is present in only a certain proportion of cases, and, also, that of the 
instances in which haemoptysis occurs, extravasation into the pulmo- 
nary parenchyma coexists in an exceedingly small ratio. It follows 
that the expectoration of blood cannot be cotmted on as a diagnostic 
indication when pulmonary apoplexy actually exists, and that still 
less is the existence of pulmonary apoplexy to be predicated on the 
expectoration of blood. 

Laennec also entertained the belief that the physical signs of an 
apoplectic extravasation "were quite distinctive. According to him, 
absence of respiratory sound over a limited area, and the presence of 
the crepitant rale around the borders of this space, constitute a com- 
bination which is diagnostic, provided haemoptysis be present. Obser- 
vations, however, have failed to establish the constancy of these 
associated phenomena. With reference to the crepitant rale in this 
connection, it is to be borne in mind that the distinction between it 
and the sub-crepitant, has been made since the time of Laennec. 



PULMONARY APOPLEXY. 523 

The diagnosis of pulmonary apoplexy, in fact, can rarely be made 
with precision, and in many cases is wholly impracticable. The 
most experienced auscultators concur in the remark made by Bouil- 
laud, that the occurrence of extravasation is rather guessed at than 
diagnosticated. Aside from heamoptysis, cough, expectoration, and 
embarrassment of the respiration, are incident to the affection, but 
they are not in themselves distinctive, inasmuch as they are incident 
to other forms of disease. The suddenness with which embarrassed 
respiration, in connection with hemorrhage and other pulmonary 
symptoms, is developed, is a circumstance which should give rise to a 
suspicion of extravasation. A patient attacked at once with these 
symptoms, having been previously free from all evidence of pulmonary 
disease, has some affection of rapid development, and this feature is 
accounted for on the supposition of an apoplectic effusion. Pulmo- 
nary apoplexy is very rarely, if ever, a primary affection. It occurs 
secondarily, in the vast proportion of cases, as a result of disease of 
heart, consisting in either hypertrophy of the right ventricle, or 
mitral valvular affection involving obstruction at that orifice. The 
latter is the lesion with which it is most frequently associated. The 
symptoms due to the extravasation will therefore be commingled with 
those proceeding from the heart affection. Its connection with disease 
of heart, however, is a point to be taken into account in the diag- 
nosis. The presence of signs and symptoms pointing to pulmonary 
apoplexy derive considerable force from the coexistence of cardiac 
lesions, especially contraction or patescency of the mitral orifice. 

Dulness on percussion over a limited space, situated not at the 
summit of the chest, and more especially if found on the lateral or 
posterior surface, together with the auscultatory evidence of solidifi- 
cation, or suppression of respiratory sound, and accompanied by diffi- 
culty of respiration suddenly developed, warrants a strong suspicion 
of extravasation. The sudden development of embarrassed respira- 
tion is a point of some significance ; but so fjir as the physical signs 
are concerned there is nothing in them to distinguish it from the 
solidification produced by gangrene, oedema, or carcinoma. If 
haemoptysis be added, or if the expectoration consist in part of a 
dark, grumous, bloody liquid, there is ground for a presumption of 
the existence of pulmonary apoplexy. The non-occurrence of fetid 
expectoration strengthens this presumption by excluding gangrene. 
A bloody expectoration may occur equally in carcinoma, but other 
symptoms and signs denoting carcinoma may be absent so as to 
render it highly probable that this affection does not exist. 



524 DISEASES OF THE RESPIRATOEY ORGAKS. 

If the physical signs which I have supposed to be present are 
found at the summit of the chest in front or behind, a tuberculous 
deposit is vastly more probable than an apoplectic extravasation ; 
and under these circumstances the occurrence of haemoptysis renders 
the fact of tuberculosis still more probable. The liability to attri- 
bute tuberculous solidification accompanied by haemoptysis, in certain 
cases, to pulmonary apoplexy, has been referred to in the chapter on 
pulmonary tuberculosis. In attempting to make the differential 
diagnosis from a tuberculous deposit, situation is an important point, 
observations showing that extravasation is not likely to occur at or 
near the apices of the lungs, where tubercle is first deposited in the 
vast majority of cases. The coexistence of heart disease is another 
point possessing diagnostic significance in this discrimination, since 
it is rarely found associated with pulmonary tuberculosis. 

It is thus seen that considerable uncertainty attends the diagnosis, 
in cases in which the extravasation is sufficient in amount to give 
rise to well-marked physical signs. And it is to be borne in mind 
that in a certain proportion, perhaps the majority of cases, the result 
of physical exploration is negative. In the absence of physical 
signs it is in vain to attempt to reach even a probable opinion as to 
the existence of the affection. 

The difficulties in the way of the diagnosis of pulmonary apoplexy 
render its infrequency a subject for congratulation, irrespective of 
the dano;er to life which belonsrs to it. The diaojnosis involves a 
grave prognosis. In a case which came under my observation, in 
which it occurred as a complication of tuberculous disease of the 
lungs, death took place so suddenly as to call for a coroner's inquest. 

SUMMARY OF PHYSICAL SIGNS BELONGING TO PULMONARY APOPLEXY. 

The evidence of circumscribed solidification, furnished by percussion 
and auscultation, present in a certain proportion of cases only ; moist 
bl'onchial rales occasionally observed ; cavernous signs succeeding 
those denoting solidification in some instances. 

Cancer of the Lungs. 

Notwithstanding the extreme infrequency of cancer of the lungs, 
the disease possesses practical interest in consequence of the recent 
investigations of Stokes, Walshe, and others, with reference to its 
diagnostic characters, which are better established and more reliable 
than in the instance of the affection last considered. The form 



CANCER OF THE LUNGS. ' 525 

of cancer distinguislied as encephaloid is that generally present 
Tvhen the lungs are the seat of a malignant disease. Examples 
of the affection called colloid are exceedingly rare. The morbid de- 
posit is found either in circumscribed masses or nodules, varying from 
the size of a hazel-nut to that of an orange, more or less num.erous, 
sometimes limited to one lung, but oftener existing in both sides ; or, 
it is infiltrated more or less extensively into the air-cells,^ giving rise 
to a condition analogous to hepatization. It is stated that when the 
disease is primary, the cancerous deposit is infiltrated, and that the 
nodulated variety occurs when the disease is developed in the pulmo- 
nary organs secondarily, i. e. subsequent to a deposit in other organs. 
According to Rokitansky, the latter is met with oftener than the 
former variety. 

In proportion to the cancerous growth the pulmonary structure is 
destroyed, and the surrounding parenchyma undergoes compression. 
Solidification, then, is a morbid condition incident to the disease, re- 
presented by physical signs. In some cases, softening and elimina- 
tion through the bronchial tubes of the morbid material ensue, giving 
rise to the presence of liquid in the tubes, and the formation of 
cavities. Here are other conditions originating physical signs. In 
infiltrated cancer the affected lung suffers reduction in volume, and 
consequent contraction of the chest follows. This variety of the 
disease is usually limited to one side. The bronchial glands are 
generally involved. Liquid effusion within the pleural sac not infre- 
quently coexists. 

Cancer is very rarely found associated with a tuberculous deposit. 

Physical Signs. — If the deposit consist of a few small, dissemi- 
nated nodules, the intervening parenchyma being healthy, physical 
exploration may fail in furnishing positive results. If sufficiently 
large, numerous, or aggregated, and especially if situated near the 
surface, or if the surrounding lung-substance be oedematous, the phe- 
nomena denoting solidification will be more or less marked, viz., per- 
cussion — dulness, suppressed or enfeebled respiratory sound, with the 
characters of the broncho-vesicular or the bronchial respiration, and 
in some instances increased vocal resonance. 

In infiltrated cancer, physical signs are more constant and more 
marked. The percussion-sound is extremely dull or flat, the vesicular 
resonance over the middle third being sometimes replaced by tym- 

» Rokitansky's Path, Anat. Am. Ed. 1855, vol. 4, p. 100. 



526 DISEASES OF THE RESPIRATORY ORGAXS. 

panitic sonorousness. The dnlness may extend beyond the median 
line on the healthy side. The sense of resistance is notably in- 
creased. The respiration is bronchial, and may be either intense 
or feeble. The respiratory sound is sometimes suppressed. This 
will occur "when the calibre of the bronchus or its larger divisions 
is diminished by pressure of the cancerous deposit. Increased vocal 
resonance and bronchophony are observed in a certain proportion of 
cases. The heart-sounds are unduly transmitted. In short, the 
physical signs denote complete solidification, which is greater or less 
in extent. Ou inspection, flattening or contraction of the affected 
side is apparent, but not the depression of the shoulder and spinal 
curvature, which result from chronic pleurisy. The intercostal de- 
pressions are somewhat deepened. The respiratory movements are 
diminished. On palpation, the vocal fremitus may at first be found 
to be increased, and aftei-ward lessened. 

If softening &nd elimination take place, the physical phenomena 
correspond to the changes in the physical conditions of the afi'ected 
lung. Percussion elicits more sonorousness, which, however, must be 
non-vesicular in quality. The sense of resistance is diminished. 
Mucous rales are now more or less prominent, and the cavernous 
signs may become developed. 

On the healthy side, in cases of infiltrated cancer, or of the 
nodulated variety, if the latter be extensive, and limited to one lung, 
the respiratory murmur will be abnormally intense or exaggerated. 

Diagnosis. — With reference to the symptoms and signs involved in 
the diagnosis, it is important to distinguish cancer of the lungs from 
cancerous tumors situated exterior to the pulmonary organs, generally 
developed in the mediastinum, which extend into the chest, displacing 
the lung and other organs. I shall notice the diagnosis of mediastinal 
tumors under a distinct head. Intra-thoracic cancer, however, may 
exist simultaneously, both within and exterior to the lungs, and then 
the phenomena of both will, of course, be combined. 

Limiting, at present, the attention to cancer seated within the 
lungs, in the vast majority of cases, the march of the disease is ac- 
companied by symptoms denoting a grave pulmonary malady, and 
some of which possess diagnostic significance. A uniform symptom 
is cough, which is at first dry, but at length is attended by an ex- 
pectoration more or less abundant, and presenting variable characters. 
The expectoration consists, for a time, and always in part, of matter 



CANCER OF THE LUNGS. 527 

furnished by the bronchial mucous membrane. It assumes frequently 
a purulent appearance, and is sometimes fetid. In a certain pro- 
portion of cases, it resembles, according to Stokes, black, and accord- 
ing to Hughes, red currant jelly. This appearance, due to an inti- 
mate admixture of blood with the morbid products, is regarded by 
the observers just named as highly characteristic of the disease. 
Pure haemoptysis occurs in a large proportion of cases during the 
course of the disease ; according to Walshe, the ratio being seventy- 
two per cent.^ It is possible that the microscopical characters of 
cancer may be discovered in the sputa. Pain, more or less severe, in 
the affected side, is a pretty constant and persisting symptom. The 
pain differs in character in different cases, being acute or lancinating, 
dull and burning. This symptom is valuable with respect to the 
diagnosis. The respirations are increased in frequency in proportion 
to the extent of solidification or destruction, and sometimes, although 
rarely, dyspnoea becomes a prominent symptom. Dysphagia is a 
symptom noticed in some cases of pulmonic as well as mediastinal 
cancer. The pulse, for a considerable period during the progress 
of the disease, is not notably increased in frequency. Marked 
febrile movement is rarely present. This is a negative fact of im- 
portance in a diagnostic point of view. Emaciation is generally less 
marked than in most cases of tuberculosis. The complexion, in a 
certain proportion of cases, denotes anaemia, and may present the 
waxen or straw-colored hue, which has been considered heretofore as 
highly significant of malignant disease. 

In a small proportion of cases, cancer of the lungs is a latent dis- 
ease as regards symptoms. And when it is limited to small, cir- 
cumscribed, disseminated deposits, and especially if these are about 
equally distributed in both lungs, physical exploration, as already 
stated, may not furnish positive results. But if the extent of the 
affected lung be sufficient to give rise to the signs of solidification, 
which is true of the great majority of the cases of infiltrated cancer, 
the symptoms and history, taken in connection with the results of 
exploration, are generally adequate to establish a diagnosis. Under 
these circumstances, the nature of the disease is ascertained not so 
much from any positive diagnostic characters, as by excluding other 
chronic affections also involving solidification of lung, and certain of 
the symptoms as well as signs which belong to cancer. 

* The analysis by Walslie embraced cases of cancer of the mediastina as well as of 
the lungs. 



528 DISEASES OF THE RESPIRATORY ORGANS. 

As remarked by Walshe, infiltrated cancer can only be confounded 
with diseases lessening the bulk of the lung. These affections, ex- 
clusive of cancer, are tuberculosis, chronic pneumonitis, chronic pleu- 
risy, and the affection called by Corrigan cirrhosis of the lung. It 
will suffice to notice the points involved in the differential diagnosis 
from these affections respectively. 

In pulmonary tuberculosis, the physical signs of solidification, with 
contraction of the summit of the chest, are equally present ; and in- 
asmuch as this affection is as frequent as cancer is rare, the practi- 
tioner is very likely to mistake the latter affection for phthisis. More- 
over, certain of the symptoms highly characteristic of tuberculosis 
belong to the history of cancer, viz., haemoptysis, emaciation, and 
ansemia. The distinctive circumstances pertaining to both signs and 
symptoms, are, hoAvever, striking. In cancer, the solidification fre- 
quently remains for a considerable or even a long period, i. e. several 
months, without material change ; in other words, without softening 
and excavation, as evidenced by the development of mucous rales, 
gurgling, and the cavernous modification of respiration. On the 
other hand, with an equal amount of tuberculous deposit, the signs 
just mentioned would be expected to supervene more uniformly, and 
after the lapse of a shorter period. And as the softening and 
elimination of tubercle go on, in general, more extensively as well as 
more rapidly, these signs become more strongly marked than in the 
course of cancer. In the latter affection, the phenomena due to the 
solidification, viz., dulness or flatness, with suppression of respiratory 
sound, or the bronchial respiration, and perhaps bronchophony, con- 
tinue without the addition of the contingent adventitious sounds, or 
rales, for a longer time than in phthisis. In infiltrated cancer, the 
deposit, being extensive, and, in the majority of cases, limited to one 
lung, the affection differs from phthisis in presenting the signs of 
solidification exclusively on one side, the other side affording no evi- 
dence of disease. With a similar amount of tubercle in one lung, 
more or less of the evidences of a tuberculous deposit in the other 
lung would be expected. The two circumstances just mentioned are 
the strong points in the differential diagnosis, so far as concerns the 
physical signs. As regards symptoms, the expectoration of matter 
resembling currant jelly, which occurs in a certain proportion of the 
cases of cancer, is foreign to the semeiological history of tuberculosis. 
Febrile movement, or marked acceleration of the pulse, which, in the 
majority of cases, characterize the march of phthisis, do not occur 



CANCER OF THE LUNGS. 529 

till late in the progress of cancer. Pain in the chest, exclusive of 
that attending the occasional attacks of dry, circumscribed pleurisy, 
does not belong to the history of phthisis. The pleuritic stitch-pain 
just referred to, is readily recognized, and constitutes, as has been 
seen, one of the characteristic symptoms of tuberculous disease. 
Cancer, on the other hand, generally gives rise to persisting pain, 
which becomes thus a prominent feature of the disease. The dis- 
turbance of the circulation is disproportionately less, compared with 
the pulmonary symptoms, than in cases of tuberculous disease, the 
pulse frequently, for a considerable period, remaining nearly or quite 
natural. Emaciation is not so prominent a feature early in the career 
of the disease as in the majority of the cases of phthisis. In a cer- 
tain proportion of cases, cancer of the lungs coexists with a cancerous 
deposit in some part where its characters are open to inspection or 
manual examination. The existence of cancer elsewhere than in the 
lungs, with pulmonary solidification, renders it altogether probable 
that the latter is cancerous ; and if, after the extirpation of a can- 
cerous part, the occurrence of pulmonary symptoms and signs denotes 
some grave affection of the lungs, the development of cancer in these 
organs is highly probable, since observations show that, under these 
circumstances, they are apt to be invaded. 

Attention to the foregoing points of distinction will, probably, in 
a large proportion of cases, enable the practitioner to discriminate 
clinically between the two affections. 

Chronic pneumonitis is nearly if not quite as rare an affection as 
cancer of the lungs. It is attended by contraction of the chest, but 
in a less degree than infiltrated cancer. A cancerous deposit differs 
from tubercle, as has just been seen, in undergoing less uniformly 
and more slowly the processes of softening and elimination. On the 
other hand, it differs from chronic pneumonitis in the greater fre- 
quency with which it eventuates in excavation. In extensive cancer- 
ous solidification, the percussion-dulness sometimes shows the exten- 
sion of the disease laterally beyond the median line. This does not 
occur in chronic pneumonitis. Chronic pneumonitis generally succeeds 
the acute form of the disease. Acute pneumonitis is an antecedent 
of cancer only as a coincidence. The lower lobe of the lung is most 
prone to be attacked with inflammation. A cancerous deposit is most 
apt to take place in the superior lobe. Pure haemoptysis, which oc- 
curs in a large proportion of cases of cancer, very rarely, to say the 
least, is a symptom of pneumonitis ; nor is the jelly-like expectora- 

34 



5S0 DISEASES cr izz r. zspiaAToay oseAWS. 

t:?:i ^i-^n'Ti-T :" ?^::?Tr :': :^:"7^ :t: -^i^^e? of the latter -.Zt:-::^, 
Z T z : izr ; : :: : z t : ::: i-;T~liere than in :z: 'ii^r. 
L: - : ir : T rnostic sdgnijicaiice as in the differential diagnosis 



~_ _: L ; plenrisy, marked contraction of the chest follows the ab- 
sorption of a eonsiderahle portion of the liquid effimon. Assuming 
that £ : 1 5 r : : ::z f = i ^ rr observation at this period of the disease, there 
is s " : ^ i - ::~ : ii aking it for cancer. Butj in general, if a case 
L T : :: T rrved, either from the beginning, or an earlj period 

YL : T ^ T : T revioiis histoiy wiU supply facts sufficient, in 

c : 1 -L :: z :_ rzt signs and symptoms, to render the character 
of the disease abnr. :'ear. The distinctiTe circmnstances, how- 

ever, are not less a^ . in the other affections which are to be 

excluded in anivizig i: :__ ^i^osis of cancer. The contraction of 
the chest is greater and m: ^ ^ ZtTiI on the affected side in chronic 
pleurisy : the shoulder is «i r r spine frequently curved in a 

lateral direction, the inter: : ^ ercept at the sominit. nar- 

rowed, and the respiratory — : : : : z : liminished. Ul t s s :i e 
liquid effusion be complete ~ f i nd absen : t : : ": :- 

ratory sound extend fiwn :-^T T ;: z ^ :-^^!-^ :: : :r. 

height- But it is to be bcrir :_ z: z^ : z t i ~. ~ :L .: : z - 
sion, may occur as a complication of cancerous disease. The puim - 
nary and general symptoms are not sufficiently graTe for an amour.: 
of cancerous disease sufficient to account for the physical signs. 
Cough and expectoration are frequently slight or wanting in chronic 
pleurisy. The strength and weight are better preserved. Haemop- 
^sis occurs but rarely, unle^ the pleurisy be complicated with 
tubercle. The jefly-like expectoration peculiar to cancer is never 
observed- 

Cirrhosis of the lung with dilatation of the bronchise presents, in 
connection with thoracic contraction, this distinctive feature of 
cancer, viz., persistency of the signs of solidification. In the differ- 
ential diagnosis the existence of the latter affection is determined or 
disproved hj the- absence or presence of bloody expectc^rrziiz and 
pure hsemoptysiB ; by pain being either wanting or pron zzi: ; by 
the evidence of a grave affection, which belongs to the hisi^Ci j ii ciin- 
cer, derived from loss of weight and strength, and the physiognomy 
indicating a malignant disease ; or, on the other hand, the deficiency 
of this evidence, which, comparatively speaking, distinguishes cirrho- 
sis, and by the existence or non-existence of cancerous deposit in 
situations accessible to direct examination. 



CANCER IN THE MEDIASTINUM. 531 



SUMMARY OF THE PHYSICAL SIGNS BELONGING TO CANCER OF 
THE LUNGS. 

Absence of positive signs, if the cancerous deposit be in the form 
of small, disseminated nodules, distributed in both lungs. Dulness 
on percussion with the auscultatory signs of solidification, when the 
nodules are sufficient in number and size, agglomerated, accompanied 
by oedema, and especially if limited to or more abundant on one side. 
In cancerous infiltration, contraction of the chest over the aff'ected 
lung, and lessened respiratory movement. Marked diminution or 
absence of vesicular resonance on percussion, with or without the 
substitution of tympanitic sonorousness, and marked resistance of 
thoracic wall. Bronchial respiration, or suppression of respiratory 
sound, with or without increased vocal resonance, or bronchophony, 
and vocal fremitus. Undue transmission of the heart-sounds. After 
a time, mucous rales, gurgling and cavernous ; the percussion-reso- 
nance greater than previously, but tympanitic. Supplementary 
respiration on the unaffected side. 

Cancer in the Mediastinum. 

Intrathoracic cancer exterior to the lungs may originate in the 
pleura or mediastinum, forming one or more tumors, of greater or 
less size, displacing and compressing the pulmonary organs, the 
trachea and bronchi, the heart and its large vessels, the oesophagus, 
thoracic duct, and nerves, and giving rise to symptoms and signs 
which distinguish it from a cancerous affection, properly speaking, of 
the pulmonary organs. Although perhaps strictly more appropriate 
to include cancerous growths exterior to the lungs, in the group of 
diseases affecting the pleura, which will constitute the subjects of 
the succeeding chapter, it will be more convenient and useful to 
notice them in the present connection, in order to present their diag- 
nostic traits in contrast with those which belong to the same disease 
seated within the pulmonary organs. And it will answer every pur- 
pose to notice cancer in the mediastinum exclusively, since, with cer- 
tain qualifications, which will readily suggest themselves, the points 
involved in the diagnosis are the same as when the affection is deve- 
loped at any other point within the chest exterior to the lungs. More- 
over, the principles of diagnosis which relate to cancer in the medi- 
astinum will apply, with very few modifications, to other tumors 



532 DISEASES OF THE RESPIRATORY ORGANS. 

having the same seat ; and, therefore, it will suffice to consider the 
symjDtoms and signs belonging to the former, as representing the 
latter, irrespective of certain circumstances distinctive of a cancerous 
affection, which will be briefly alluded to. 

A fact already stated is to be borne in mind, viz., that cancer ex- 
ists exterior to, and at the same time within the lungs, in a certain 
proportion of cases. 

A cancerous growth originating in the mediastinum, will extend 
into one or both sides of the chest, in proportion to its magnitude and 
the direction laterally which it takes. It has been oftener observed 
to extend into the right than into the left side. In some cases it 
attains to such size as to fill nearly the entke thoracic space on one 
side, and also a considerable portion of that on the opposite side. 
An instance of this kind is given by the late Prof. Swett,^ in which 
the tumor weighed eleven and a half pounds. The tumor may ex- 
tend in either lateral direction about equally, compressing both lungs 
alike, and giving rise to similar physical phenomena on both sides of 
the chest. 

Pliysical Signs. — Diminution or abolition of vesicular resonance on 
percussion extends from the median line on one or both sides over an area 
within which the tumor is either in contact with or in close proximity 
to the thoracic parietes. The vesicular resonance, especially at the 
summit of the chest in front and behind, near the median line, may 
be replaced by a tympanitic or tubular sonorousness transmitted from 
the trachea and bronchi. A tympanitic sonorousness may also be found 
over the middle and lower parts of the chest, and an amphoric modi- 
fication is sometimes observed. The source of the sonorousness in 
the latter instance is probably gastric or intestinal. A marked de- 
gree of tympanitic sonorousness in either situation is an exceptional 
phenomenon. As a rule, percussion over the tumor elicits dulness or 
flatness. And this dulness or flatness being dependent on the pre- 
sence of a solid mass which is at least attached at the point whence 
it springs, the area over which it extends remains unaltered, or nearly 
so, in different positions assumed by the patient. If the tumor 
extend, so as to come into contact with the heart or liver, the relative 
positions of the latter to the tumor may frequently be ascertained by 
an alteration in the percussion-sound. The sense of resistance felt 
by the finger employed in percussing or in pressure, made expressly 
with reference to this point, is notably increased. 

1 Diseases of the Chest, page 335, 



CANCER IN THE MEDIASTINUM. 533 

Auscultation may discover strongly marked the characters of the 
bronchial respiration at the summit of the chest in front and behind, 
extending more or less therefrom over the chest ; or these characters 
may be feebly manifested ; or, again, the respiratory sound may be 
abolished over a greater or less portion of the space in which percus- 
sion-dulness or flatness are observed. These variations depend on the 
relations of the tumor to the trachea and bronchi, and on the amount 
of compression which may be made on these portions of the air-pas- 
sages. The bronchial respiration, when present, may be heard either 
over the compressed lung at the summit, or over the tumor, or in both 
situations. Its limitations, therefore, as well as those of suppressed 
respiratory sound, do not always rigidly correspond to the space occu- 
pied by the tumor. Adventitious sounds, or rales, are present as 
contingent phenomena, due to coexisting bronchitis, or, if a cancerous 
deposit within the lungs have taken place, to its softening and elimi- 
nation. The sounds of the heart are unduly transmitted. 

The vocal signs are variable. There may be marked increase of 
the vocal resonance and bronchophony, or these phenomena may be 
wanting. Even pectoriloquy may be present. ■ 

Pressure of the tumor on the aorta may occasion an arterial thrill 
and bellows murmur. 

Inspection and palpation furnish important signs. Dilatation of 
the chest distinguishes cancerous growths developed exterior to the 
lungs, after they have attained a certain size. The dilatation is partial 
or extends over the whole of one side, or affects both sides, according 
to the size and direction of the morbid growth. It may be confined 
to the sternum and costal cartilages ; but as the resistance is less in 
a lateral direction, the tumor generally extends into the chest, instead 
of producing a circumscribed enlargement in the situations just men- 
tioned. The intercostal spaces are widened, and in some cases are 
dilated or even bulging, and remain unaffected by the act of inspira- 
tion."" The heart may be removed in various directions from its normal 
position. In the case already referred to, reported by Prof. Swett, 
it was found to the right of the sternum, where its pulsations had 
been observed during life. If the tumor extend to the base of the 
chest, the diaphragm and the subjacent viscera may be depressed. The 
superficial thoracic veins of the afi"ected side may be enlarged, accom- 
panied with a livid hue and oedematous infiltration. Fluctuation is 
very rarely observed, but this was present in the case reported by 

' Vide case reported by Prof. Swett (op. cit. p. 334), in which bulging was observed. 



534 DISEASES OF THE EESPIRATOKT ORGAXS. 

Prof. Swett. The vocal fremitus over the tumor is abolished. In 
proportion as the chest is dilated, its contraction with the act of ex- 
piration is restrained, and the range of expansive movement correspond- 
ingly lessened. 

Mensuration shows an increase of the size of the chest ; an abnor- 
mal disparity in this respect existing between the two sides, if the 
dilatation be confined to one side, or if the two sides are unequally 
dilated. This disparity is manifested by semicircular measurements, 
by a comparison of the antero-posterior diameters, and by a greater 
distance from the nipple to the mediae line. 

Diagnosis. — The compression and displacement of the pulmo- 
nary organs, air-tubes, vessels, oesophagus, etc., by a mediastinal 
tumor, give rise to a variety of symptoms, as well as signs, which 
are measurably distinctive when contrasted with cancer of the lungs. 
Iji proportion to the extent to which the lungs, air-passages, pulmo- 
nary artery, and veins are compressed, the dyspnoea becomes a pro- 
minent symptom. The suffering from want of breath, as the tumor 
increases m size, may be extreme, rendering the recumbent posture 
insupportable. Pressure on the venous trunks communicating with 
the veins of the head and upper extremity induces congestion of these 
parts, which occasions tumefaction, lividity, and oedema. When the 
pressm-e is chiefly on the vessels of one side, the distension of the 
veins, together with tumefaction and oedema, are limited to that side. 
Heaviness and somnolency are incident to cerebral engorgement. 
Pressure on the oesophagus may occasion an obstruction to the pas- 
sage of alimentary substances, and hence results dysphagia, which is 
more likely to be prominent as a symptom than in cancer seated in 
the lungs. 

Diminishiug the calibre of the arteria innominata or the subclavian 
on one side, the radial pulse of the extremity corresponding to that 
side may be perceptibly less in size and force than that of the oppo- 
site extremity. 

If the important nerves, the par vagum, recurrent, or the phrenic, 
are included in the parts compressed, here is another source of dis- 
turbance of the respiration, affecting the diaphragmatic action, and 
the respiratory movements of the glottis. Hydi-othorax or pleurisy 
leading to the formation of pus (empyema) are contingent affections, 
giving rise to the phenomena dependent on liquid within the pleural 
cavity. Pain in the chest is more or less persisting and severe ; 



CANCER IN THE MEDIASTINUM. 535 

cough, haemoptysis, and the jelly-like expectoration referred to in 
connection with cancer of the lungs, may occur in the course of this 
affection, and toward the close of life anasarca is usually present. 
Perforation of the thoracic wall, of the lung, oesophagus, or some of 
the large vessels, is liable to occur, giving rise to additional trains of 
symptoms, or proving the immediate cause of a fatal termination. 

Numerous, diversified, and grave as are the results just enume- 
rated, Dr. Walshe states that he has seen them united in one and the 
same individual. 

Differentially, the diagnosis of mediastinal tumors involves, in the first 
place, a discrimination from cancerous infiltration of the lungs, and 
the several affections with which the latter is liable to be confounded. 
The distinctive circumstances are those which have relation to dilata- 
tion of the chest, and the pressure of the tumor on the vessels, air- 
passages, nerves, oesophagus, heart, etc. The phenomena due to en- 
largement, displacement, and compression, are rarely present, and 
never to the same extent in cancer seated in the lungs, in chronic 
pneumonitis, in tuberculosis, or in pleuritis after partial absorption. 
These phenomena, constituting a large share of the list of symptoms 
and signs just given, are characteristic of intrathoracic tumor exterior 
to the lungs. Moreover, from pneumonia, and tuberculosis, and chronic 
pleuritis, a cancerous tumor in the mediastinum may often be distin- 
guished by the occurrence, in the course of the disease, of certain of 
the symptoms which are observed in a cancerous affection of the 
lungs, viz., haemoptysis, and the currant-jelly expectoration. And in 
this connection the fact may be again stated, that mediastinal cancer 
frequently coexists with a cancerous affection of the lungs. 

In the second place, mediastinal tumor is to be discriminated from 
enlargement of heart, pericarditis with large effusion, and aortic aneu- 
rism. Many of the phenomena incident to the dilating, compressing, 
and displacing effects of a mediastinal tumor, which have been enu- 
merated, are^Common to the affections just named. The differential 
diagnosis turns on the presence or absence of the symptoms and signs 
distinctive of these affections ; in other words, in arriving at the con- 
clusion that the phenomena proceed from a mediastinal tumor, and 
not from either of these affections, the latter are to be excluded. To 
consider the negative points warranting their exclusion, would involve 
a consideration of their positive diagnostic criteria ; for these, the 
reader must be referred to works which treat of the diseases of the 
heart and arteries. 



536 DISEASES OF THE RESPIRATORY ORGANS. 

In the third place, the affections for which there is the most liability of 
mediastinal tumor being mistaken, are chronic pleurisy, prior to retrac- 
tion of the chest, and empyema. Here we have the phenomena due 
to dilatation, displacement, and in a certain amount to compression, 
combined. Moreover, the fact is not to be lost sight of, that liquid 
effusion within the pleural sac, either purulent or serous, may exist as 
a complication of mediastinal cancer, or of a cancerous affection of 
the lungs. This complication renders the diagnosis less intricate 
than might at first be supposed. The phenomena due to compres- 
sion, viz., dyspnoea, tumefaction of face, lividity, swelling of the 
veins, dysphagia, are not present to the same extent in chronic 
pleuritis, or empyema, even when the chest is largely dilated. In a 
case of mediastinal tumor involving a considerable amount of dilata- 
tion of the chest, the effects of pressure on large vessels, trachea, oeso- 
phagus, and nerves, may be expected to be in a marked degree greater 
than when an equal amount of dilatation is caused by pleuritic effusion 
alone. This is a capital point of distinction. Moreover, the distinc- 
tive characters of cancer pertaining to the expectoration, viz., haemop- 
tysis, and the peculiar jelly-like matter, do not occur in chronic 
pleurisy or empyema. Hence, if these symptoms are present, they 
are diagnostic of a cancerous affection ; and the coexistence of 
cancer in some part where the fact can be ascertained by examina- 
tion, here, as in other instances, is highly significant. Physical ex- 
ploration furnishes certain distinctive points. The bronchial respira- 
tion, and bronchophony are marked in cases of chronic pleuritis with 
large effusion, or of empyema, only in rare, exceptional instances. 
Although not uniformly observed in connection with cancer in the 
mediastinum, they are much more frequently present, and not infre- 
quently strongly marked. The dilatation of the chest from the dis- 
tension of liquid is more uniform than from an intrathoracic tumor. 
The intercostal depressions are more constantly and in a more marked 
degree affected by distension from liquid. It is rare that bulging 
between the ribs occurs from the distension of a tumor, while it is 
the usual effect of great enlargement from the presence of liquid. A 
sense of fluctuation is an exceptional phenomenon in the former case, 
and occurs more frequently in the latter."" Finally, it is extremely 

* Bulging and fluctuation are stated not to oecur in dilatation from the presence of an 
intrathoracic tumor, but both were observed in a case of cancer in the mediastinum, 

already referred to, reported by Prof. Swett, in which a trifling quantity of liquid only 
existed within the pleural sac. 



CANCER OF THE MEDIASTINUM. 537 

rare in cases of cliroiiic pleurisy with large effusion, or in empyema, 
to find vesicular resonance on percussion, denoting the presence of 
pulmonary normal substance below the level of the liquid. In cases 
of mediastinal tumor, on the other hand, it will frequently, and per- 
haps generally, be found that the physical evidence of lung containing 
air in the air-cells is obtained in parts of the chest in which, if the 
morbid phenomena were due to liquid effusion, the gravitation of the 
fluid would be almost sure to abolish both the vesicular resonance and 
respiration. 

The data upon which a probable opinion that a mediastinal or 
other intrathoracic tumor is of a cancerous nature, are briefly the 
following : Haemoptysis, and the characteristic jelly-like expectora- 
tion, or, possibly, the presence of cancerous matter, determined 
microscopically in the sputa, these phenomena, probably in the majo- 
rity of cases, indicating a coexisting deposit of cancer within the 
lungs; and the existence of a cancerous affection in other parts of 
the body, in which the fact of its existence may be positively ascer- 
tained. 

It is proper to state, that in treating of cancer of the lungs and in 
the mediastinum, I have relied on the observations of others, with- 
out having been able, owing to the infrequency of the disease, to 
verify their correctness by my own clinical studies ; and I would 
particularly express my indebtedness to the treatise by Dr. Walshe, 
to which, in the course of this work, frequent reference has been 
already made. 



CHAPTER YII. 

ACUTE PLEURITIS — CHRONIC PLEURITIS — EMPYEMA — HYDRO- 
THORAX — PNEUMOTHORAX — PNEUMO-HYDROTHORAX— PLEU- 
RALGIA— DIAPHRAGMATIC HERNIA. 

The group of diseases to which this chapter is devoted, consists of 
affections which are either seated in the pleura, or, as in the case of the 
two last named, in their situation are related more closely to this than 
to any other of the structures entering into the anatomical composition 
of the pulmonary organs. They form an interesung and important 
class of the diseases of the respiratory system. As regards their 
diagnosis, it will be found that, without the aid derived from physical 
exploration, they are frequently detected with great difficulty, and, 
indeed, in many instances cannot be distinguished from each other, 
or from certain of the diseases treated of in the preceding chapters. 
On the other hand, by means of physical signs in conjunction with 
symptoms, the discrimination is in general made with facility and 
positiveness. I shall consider these affections, respectively, in the 
order in which they are enumerated in the heading of this chapter. 



Acute Pleueitis. 

In point of frequency this affection ranks third in the list of acute 
pulmonary diseases, bronchitis and pneumonitis taking precedence in 
this regard. It occurs either as an independent or a concomitant 
pulmonary affection. When developed as a complication of some 
other disease of the lungs, as in tuberculosis and pneumonitis, the 
inflammation is usually limited to a portion of the pleural surface : 
in other words, the pleuritis is circumscribed. Its occurrence in 
connection with the diseases just named, has been noticed in the 
chapters devoted to their consideration. When not thus consecutive, 
the inflammation is usually general, i. e. it extends more or less over 



II ACUTE PLBURITIS. 539 

11 
! 

I the entire pleural membrane on one side. To this rule, however, 
j there are exceptions. The inflammation is sometimes limited, con- 
j stituting partial pleurisies, which are called, according to the portions 
i affected, costal, pulmonary, diaphragmatic, mediastinal, and inter- 
lobar. Again, the pleuritic inflammation may be confined to one 
side, or affect both sides. In the former case it is single^ and in the 
latter double pleuritis. In treating of the physical signs and diag- 
nosis of the disease, reference will be had, in the first place, to acute 
general pleuritis. Partial pleurisies will be briefly noticed after 
treating of chronic pleuritis. 

Acute general pleuritis is divided by some writers into several 
stages. For clinical convenience, and with especial reference to 
variations in physical signs, it suffices to recognize three different 
periods in the progress of the disease. 1st. The period from the 
commencement of the inflammation to the accumulation of an appre- 
ciable quantity of liquid effusion within the pleural sac. This period 
will comprise the dry and plastic stages of some writers. 2d. The 
period during which the liquid is either accumulating or remains sta- 
1 tionary. This period may be called the stage of effusion or of liquid 
; accumulation. 3d. The period when the liquid effusion is being re- 
moved by absorption. Perforations of the thoracic wall, and of the 
lung, by which the effused liquid is evacuated, in the one case directly 
and in the other case indirectly through the bronchial tubes, are acci- 
I dental events of rare occurrence, and do not, therefore, belong to the 
natural history of the disease, as deduced from the phenomena occur- 
ring in the large majority of cases. 

The physical conditions pertaining to the morbid anatomy, which 
are represented by signs in these three periods, are the following. 
First. The presence of plastic lymph, either in patches, varying in 
size, and more or less numerous, or sometimes diffused over the whole 
of the inner surface of the pleural sac. It has been hypothetically 
assumed that, prior to this deposit, there exists for a time an abnor- 
mal dryness of the membrane, which may give rise to acoustic phe- 
nomena. Second. The presence of Ifquid, which speedily gravitates 
to the bottom of the sac, compressing the lung, and displacing it in 
a direction upward and backward, except it have become fixed at 
certain points by previous morbid adhesions. The accumulation of 
liquid in some cases in sufficient quantity to expel by compression 
the air from the lung, reducing it to a small condensed mass (carni- 
fication) ; at length enlarging the size of the chest, depressing the 



540 DISEASES OF THE EESPIRATORY ORGAXS. 

diaphragm and subjacent organs, displacing the heart, and producing 
various alterations in the relations of the parts composing the tho- 
racic parietes. Third. The diminution and ultimate disappearance 
of the effused liquid, accompanied by an expansion of the compressed 
lung, which regains, only after a time, and frequently never, its 
former volume. Contraction of the chest, and often persisting or 
permanent alterations in form, and in the relations of parts, the re- 
verse of those which have occurred at a former stage. The pleural 
surfaces, in proportion as the liquid effusion diminishes, again coming 
into contact, roughened by a fibrinous coating more or less solidified, 
and in progress of organization. Finally, adhesion of the pulmonary 
and costal pleurse by means of the complete organization of the in- 
termediate plastic lymph. 

The foregoing sketch of the physical conditions belonging to the 
different stages of the disease, will apply equally to acute and chronic 
pleuritis, and as regards the effects of an abundant accumulation of 
liquid on the walls of the chest and the intrathoracic organs, they 
are generally much more marked in the latter variety of the disease. 

Physical Signs. — xA.s remarked by Yalleix, the phenomena belong- 
ing to the natural history of pleuritis, notwithstanding the frequency 
of the disease^ have not been studied, by means of the analysis of 
clinical records, to the same extent as those of some other pulmonary 
affections, more especially pneumonitis and tuberculosis.^ Neverthe- 
less, its diagnostic traits, derived both from signs and symptoms, are 
well ascertained. With respect to the results of physical explora- 
tion, some interesting facts have been recently contributed. 

Proceeding to present the phenomena of the different stages of 
this affection, as furnished by the several methods of exploration, in 
the order in which the latter were taken up in the first part of this 
work, the signs obtained hj percussion are to be first noticed. Prior 
to the accumulation of liquid in sufficient quantity to gravitate to the 
bottom of the chest, and to occupy a certain amount of space to the 
exclusion of the lung, the sonorousness on percussion may not be in 
a marked degree altered. Moderate or slight diminution of the 
vesicular resonance, replaced, according to Skoda, by a tympanitic 
sonorousness,^ is usually discovered, attributable to several causes, 

• This distinguished clinical observer and author, lately deceased, at the time of his 
death was engaged in preparing a paper on the results of percussion in pleurisy. 
[Archives Generales de Medecine^ 

2 Although much stress is laid by Skoda on modifications of resonance which he dis- 
tinguishes as tympanitic, yet. as remarked by M. Aran (his French translator and com- 



ACVTE PLEURITIS. 541 

viz., lessened expansion of the lung on account of the pain attending 
the inspiratory act ; the exudation of plastic lymph on the pleural 
surfaces, and, possibly, as contended by Woillez and Hirtz, the pre- 
sence, during this stage, of a thin stratum of liquid uniformly diffused 
over the lung. The latter, which is called laminar, in distinction 
from gravitating effusion, is questionable ; and that the lessened ex- 
pansion of the lung is the chief cause of the diminished resonance, 
may be shown by the fact that a deep inspiration (if the patient will 
disregard the pain which instinctively leads him to repress the move- 
jl ments of the affected side), restores the normal sonorousness. Due 
I to the causes just mentioned, individually or collectively, the diminu- 
:i tion of resonance extends over the whole of the greater part of the 
affected side. During this stage especially, and frequently during 
the subsequent stages, percussion, unless lightly performed, is painful, 
owing to the soreness of the chest. 

The effusion of a sufficient quantity of liquid to gravitate, and 
elevate the lung to a greater or less extent, generally takes place 
with such rapidity, that in a large proportion of cases the opportunity 
of examining the chest during the first period of the disease is not 
offered. It very rarely happens that hospital patients come under 
observation before the disease has advanced to the second period. 
The stage of liquid accumulation may supervene even in a few hours 
after the date of the attack, and it is seldom delayed beyond the 
third or fourth day. 

When the liquid accumulates at the bottom of the pleural sac, 
elevating the lung, the vesicular resonance is abolished from the base 
of the chest upward over a space corresponding to the amount of 
effusion. The percussion-sound is flat, except a gastric or intestinal 

mentator), he nowhere gives a clear and distinct statement of the sense in which he 
intends to apply this term. The word tympanitic, as has been seen in Part I, is used 
with different latitudes of signification by different writers. From the language used 
by Skoda, in the chapter on pleurisy, it may be inferred that he considers a sound as 
tympanitic whenever it is non-vesicular, without regard to its intensity. He says, 
" The greater the depth of the exudation (in pleurisy), the duller the percussion-sound 
becomes, so tliat at least we are not able to recognize the tympanitic character of the 
dull percussion-sound." (Markham's translation, Am. Ed. p. 346.) Accepting this 
sense of the term tympanitic, which is precisely that adopted in this work, the doc- 
trine of Skoda, that whenever " the lung contains less than its normal quantity of air, it 
yields a sound which approaches to the tympanitic, or is distinctly tympanitic," is more 
readily admissible, and at the same time more intelligible. Whenever the absolute 
quantity of air is reduced in the lung, as a rule, the relative quantity contained in the 
bronchial tubes exceeds that in the cells. Hence, going no farther for an explanation, 
while the sound becomes more dull it acquires a tympanitic quality. 



542 DISEASES OF THE RESPIRATORY ORGANS. 

tympanitic sonorousness be transmitted from IdoIow, and under these 
circumstances the latter rarely occurs in a marked degree. Aboli- 
tion of vesicular resonance is invariable, and flatness is the rule. At 
the same time the elasticity of the thoracic wall is notably diminished, 
and the sense of resistance increased below the line indicating the 
upper boundary of the flatness. 

If the quantity of efi'usion be quite small, although sufficient to 
elevate the lung to some extent, tke evidence of its presence aff"orded 
by percussion, while the patient is in one position only, may be 
incomplete, owing to the normal line of flatness being vaidable in 
diff'erent persons, and on the left side in the same person at difl'erent 
periods. The results of percussion in difl'erent positions will often, 
if not generally, in such a case, establish the presence of liquid. 
Having ascertained and marked the point at which the vesicular 
resonance is lost on the posterior surface of the chest while the 
patient is in a sitting posture, let him then lie upon the face, waiting 
a moment for the liquid to gravitate to the anterior portion of the 
sac. Percussion may now elicit a vesicular resonance below the line 
indicating its lower boundary when the body was in a vertical posi- 
tion. But it is seldom that the quantity of liquid is so small as to 
leave room for doubt whether the situation of the line of flatness be 
abnormal. The efi'usion varies greatly in amount in diff'erent cases. 
Although usually less abundant in the acute than in the chronic 
variety of general pleuritis, it is usually so considerable in the former 
as to render it evident that the flatness found at the base of the chest 
is due to some morbid condition, ,which is in all probability intra- 
thoracic. 

Extending upward from the base over a third, a half, or two-thirds 
of the chest on the aff'ected side, the line of flatness, generally defined 
without difficulty by percussion, marks the level of the liquid. This 
line may be found not to pursue a horizontal direction when the 
body is in a vertical position, owing to a portion of the lung being 
fixed below the level of the liquid by previous morbid adhesions. 
For example, in a case recently under observation, in which the evi- 
dence of liquid in the left pleural cavity was unequivocal, the line of 
flatness extended horizontally through the nipple, laterally and pos- 
teriorly, to within two or three inches of the spinal column. From 
this point percussion elicited a vesicular resonance for several inches 
below a continuation of the horizontal line, showing that at its infe- 
rior posterior extremity the lung was held down by an attachment 
which was sufficient to resist the upward pressure of the liquid. 



ACUTE PLEURITIS. 543 - 

Variation in tlie line of flatness with different positions of the 
patient, in a proportion of cases, larger, as I am led to suspect, than 
is to be inferred from the opinions expressed by most writers on this 
subject, is available as a test that the flatness is due to the presence 
of liquid, provided the chest be but partially filled with the effusion. 
It is not available when the pleural surfaces are adherent above the 
level of the fluid, nor when the lung is so much compressed that its 
elasticity is destroyed. In the case just referred to, in which the infe- 
rior posterior extremity of the lung was fixed at the base of the chest, 
the evidence of the presence of liquid was afforded by percussion 
over the submerged portion of the lower lobe. When the patient 
■inclined far forward, or lay upon the face, the resonance became 
notably greater than when the position of the body was vertical ; 
showing that the portion of lung was not united to the thoracic wall 
by a close, uniform adhesion, but by bridles or bands of false mem- 
brane. 

The direction which the line of flatness is found to pursue when 
the patient is sitting or standing, serves to distinguish a gravitating 
effusion from the solidification of the lower lobe in lobar pneumonitis. 
In the latter case, as stated in the chapter on pneumonitis, provided 
the inflammatory exudation be limited to the lower lobe, and extend 
over the whole lobe, the situation of the interlobar fissure, crossing 
the chest obliquely from the fourth or fifth cartilages to the spinal 
extremity of the spinous ridge of the scapula, may be delineated by 
an abrupt change in the percussion-sound ; and this line is found not 
to vary with the different positions of the patient. It could only be 
by a coincidence hardly falling within the range of probability, that ^ 
a collection of liquid should happen to be confined by pleuritic ad- 
hesions within a space bounded exactly by the interlobar fissure. 

The loss of elasticity and sense of resistance on percussion are 
greater in proportion as the effusion is abundant, being strongly 
marked when the quantity is sufiicient to produce considerable enlarge- 
ment of the chest. 

The abolition of sonorousness is usually more complete below the 
level of a considerable quantity of liquid, than over lung solidified 
by inflammatory or other exudation. The sound in the former in- 
stance is flat ; in the latter, more or less dull, the presence of air 
within the bronchial tubes and some of the cells preventing total ex- 
tinction of resonance, which, under these circumstances, is not vesi- 
cular, but tympanitic in quality. Perfect flatness, therefore, although 
not conclusive evidence of the presence of liquid, for it may be caused 



544 DISEASES OP THE EESPIRATORY ORGANS-. 

bj an intrathoracic tumor, and occasionally even by consolidation 
of lung, warrants a strong presumption that effusion exists. And this 
presumption is rendered still stronger by the flatness being found to 
extend from the base of the chest upward, the line indicating its 
upper limits being well defined, and pursuing a direction, if the body 
be in a vertical position, extending horizontally, or nearly so, around 
the affected side.^ 

In cases in which the quantity of liquid is large, distending the 
chest, and compressing the lung into a solid mass, either flatness 
exists universally over the affected side, or, at all events, there is com- 
plete abolition of vesicular resonance, and the flatness may not be 
confined to the affected side. The accumulation of liquid, when large, 
produces a lateral displacement of the mediastinum, and the distended 
pleural sac may even encroach on the opposite side, giving rise to 
dulness on percussion, sometimes extending from half an inch to an 
inch beyond the sternum. But when the effusion is less abundant, 
the fluid rising to within a third, a half, or two-thirds of the distance 
from the base to the top of the chest, percussion over the compressed 
lung, above the level of the liquid, furnishes interesting results. The 
sonorousness is frequently increased, being greater than in a corre- 
sponding situation on the opposite side, and it becomes more or less 
tympanitic in quality. This fact had attracted, in occasional in- 
stances, the attention of several observers, but the frequency of its 
occurrence has only of late been ascertained. The existence of a 
tympanitic resonance above the level of the liquid, in cases of pleuritis, 
is probably the rule, and an exaggerated sonorousness in the same 
situation, according to the observations of Dr. Roger of Paris, pro- 
vided the quantity of liquid be neither very large nor quite small, 
exists for a greater or less period during the progress of the disease, 
in a large proportion of cases. The tympanitic resonance over the 
lung above the liquid may have a miCtallic character, resembling the 
high-pitched, peculiar sound, obtained frequently by percussing over 
the stomach. A French observer, M. ISTotta, has recently reported 
two cases in which this character of sonorousness was strongly 
marked. On the left side, it might be suspected that the sound was 

' It is stated (Traite de Diagnostic, etc., par le Docteur V. A.Racle), that when a cer- 
tain quantity of liquid is contained within the pleural sac, and the pleural surfaces are 
free from adhesions, the body being in a vertical position, the level is not exactly hori- 
zontal, the fluid rising somewhat higher behind than in front. 



ACUTE PLEURITIS. 545 

actually transmitted from the stomach ; but in the cases reported by 
M. Notta, the efiusion was on the right side.^ 

Even the cracked-metal modification of tympanitic sonorousness 
has been observed by Stokes, Walshe, Roger, and Bouillaud, at the 
summit of the chest in cases of large effusion within the pleural sac. 

During the progress of the removal of the liquid by absorption, the 
vesicular resonance gradually returns, extending from above down- 
ward in proportion as the level of the fluid is lowered. Diminution 
of vesicular resonance, however, as compared with the healthy side, 
with or without the substitution of a tympanitic sonorousness, per- 
sists for an indefinite period ; and, owing to the slowness with which 
absorption usually goes on after the quantity of liquid has been con- 
siderably reduced, flatness continues for a long time at the base of 
the chest. 

The displacement of intra-thoracic parts arising, on the one hand, 
from the pressure of a large quantity of effusion, and, on the other 
hand, from the suction-force developed by the absorption of the liquid, 
will be mentioned presently, in connection with palpation. As I 
have referred, however, already to the lateral displacement of the 
mediastinum, it may be added that, after absorption, a reverse dis- 
placement is liable to take place, and the sonorousness due to the en- 
croachment of the lung of the healthy side may be apparent even 
beyond the sternum on the side in which the effusion has existed. 

Auscultation furnishes results which, in a positive and negative 
point of view, are of great importance in the diagnosis of pleuritis. 
Feebleness of resjDiration on the affected side belongs to the period 
anterior to the stage of liquid accumulation. In quality and pitch, 
the respiratory sound is not materially changed. The intensity is 
alone altered — a result chiefly of the restrained expansion of the side 
affected. The murmur is frequently interrupted or jerking, owing to 
a want of continuity in the respiratory movements, an effect of the 
acute pains incident to this stage. 

During the period of effusion, the effects of the accumulation of 
liquid, as regards the respiratory sound, are always marked, but 
varying in different parts of the affected side ; and the phenomena 
are by no means uniform in all cases. With a very small amount of 
fluid gravitating to the bottom of the chest, producing a slight de- 
gree of compression of the lung, the respiration will be likely to con- 
tinue feeble, with some of the characters of the broncho-vesicular 

* Archives Generales de Medecine, 4 serie, t. xxii, Avril, 1850. 

35 



54:6 DISEASES or the EESPIEATORY 0EGA^'5. 

modification — ^the inspiratory sound less vesicular than on the opposite 
side, and liigher in pitch, and perhaps a prolonged expiration. K, 
however, the quantity of liquid be considerable or large, filling at 
least one-half or tvro-thirds of the chest, the results of auscultation 
practised above and below the level of the fluid, are usually in 
striking contrast with each other. Over the condensed lung, the 
abnormal characters are of the broncho-vesicular or the bronchial 
variety, according to the degree of condensation of the pulmonary 
structure. One or the other is generally more or less strongly marked. 
The intensity is variable in difi'erent cases. In some instances it is 
loud, in other instances feeble. It is oftener feeble, but as exceptions 
to the general rule, I have observed a pretty strongly marked exag- 
gerated vesicular murmur, emanating from the lung above a moderate 
efi'usion. Below the line of flatness on percussion, indicating the 
level of the liquid, the respiratory sound is frequently suppressed.^ 
The loss of sound, if the stethoscope be employed, is often abrupt, 
denoting, like the sudden loss of sonorousness on percussion, the 
height to which the liquid ascends in the chest. This account pro- 
bably expresses the rule, as respects the respiratory phenomena, above 
and below the liquid efiusion, in cases in which the latter is more or 
less abundant. But there are important exceptions to this rule. In 
some instances in which a loud bronchial respiration is heard over the 
condensed Itmg, it is propagated below the level of the liquid, and 
may extend over the entire side. This fact has been repeatedly noted 
by numerous observers, even in cases in which a very large amount 
of eSision existed, producing considerable enlargement of the affected 
side. A well-marked bronchial respiration, difiused over the entire 
side, characterizes a certain proportion of the cases of pleuritis with 
large effusion. The ratio of instances in which this occurs is yet to 
be settled by numerical analysis. The number of instances in the 
adult is not stifficient to render them other than exceptions to a 
general rule. In early life, the ratio is larger. Indeed, according to 
Swett, a bronchial respiration more or less extensive is" the rule, not 
the exception, in pleuritis affecting young children. 

In general, when a bronchial respiration is diffused over the side. 

^ The sounds of the heart are transmitted with an abnormal intensity through the 
mass of liquid. In cases in which the right side is filled with fluid, the heart-sounds 
are heard with great distinctness. Auscaltation of the heart is one of the means of 
ascertaining the displacements of this organ which are noticed presently, in connection 
with palpation. 



ACUTE PLEURITIS. 547 

in cases of abundant or large effusion, certain points of difference 
pertain to the sign, as heard above and below the level of the liquid. 
Over the condensed lung, it is more intense, and conveys the idea of 
proximity to the ear. Over the liquid, it is more feeble, and seems to 
be transmitted from a distance. 

When the effusion is very copious, filling and dilating the affected 
side, and compressing the lung into a small, solid mass, the respiratory 
sound, in the adult, at least, is usually suppressed over the greater 
portion of the chest. A bronchial respiration, either feeble or more 
or less developed, under these circumstances may frequently be de- 
tected at the summit of the chest, sometimes below the clavicles, but 
more frequently behind, above the spinous ridge of the scapula, and 
more especially in the upper portion of the interscapular region. It 
is rarely altogether wanting in one or more of these situations.* From 
the summit it may extend, with diminished intensity, conveying the 
sense of distance, over a variable area. The bronchial respiration 
will be more intense and more diffused if, in addition to the condensa- 
tion from compression, the lung is solidified, either by inflammatory 
exudation or a tuberculous deposit. A loud and persisting bronchial 
respiration warrants a suspicion of pulmonary consolidation. 

In a recent publication by MM. Monneret and Barthez, of Paris, ^ 
it is stated that the respiration over the condensed lung in.pleuritis 
may assume the characters of the cavernous and even the amphoric 
modifications. As described by these writers in the cases reported 
by them, I am unable to perceive any evidence of other than intense 
bronchial respiration. The intensity, in fact, appears to have been 
considered by them as the proof of its cavernous character. But 
a cavernous respiration is by no means always as intense as a loud 
bronchial respiration. The intensity is but an incidental element 
of both. That the two are not infrequently confounded even by ex- 

• MM. Earth and Roger found the bronchial respiration absent in 17 of 26 cases of 
pleiiritis, selected indiscriminately, as quoted in Part I of this work. The experience of 
others goes to show that it is discoverable at the summit of the chest in a larger proportion 
of cases than this; and the latter accords with my own impressions. Fmlher numerical 
results with respect to this point are to be desired. Valleix suggests that the disparity 
between the results obtained by Earth and Roger, and other observers, may be explained 
by the former studying the effect of natural or tranquil respiration, and the latter causing 
the patients examined to breathe with quickness and force. The influence of forced 
breathing in developing and increasing the intensity of the bronchial as of the normal 
respiratory sound, is well known to practical auscultators. 

2 Archives Generales de M^decine, Mars, 1S53. Vide, also, Yalleix. op. cit. vol. i, p. 
570. 



548 DISEASES OF THE RESPIRATORY ORGANS. 

perienced auscultators, I am fully persuaded. If the distinctive cha- 
racters of each (having reference especially to the relation of the 
pitch of the inspiratory and expiratory sound) are correct, as they 
have been pointed out in Part. I, and also in the chapter on Pulmonary 
Tuberculosis, it is impossible for a true cavernous respiratory sound 
to be developed in connection with solidification of lung. It is proper, 
however, to add, that the occurrence of cavernous respiration in some 
cases of pleuritis, without excavations, is admitted by Barth and 
Valleix. 

In the instances referred to in the preceding remarks, I am led to 
suppose that the bronchial respiration may have been mistaken for 
the cavernous. But a mistake may arise, if, in connection with a 
certain amount of liquid effusion, the respiration (as may occur) is 
neither bronchial nor broncho-vesicular, but intensely vesicular, or 
in other words, highly exaggerated. The latter effect on the side 
affected in single pleuritis, I suppose to be very rarely produced, but 
I haA^e already referred to it as a possible occurrence. I have observed 
this effect to be marked in a case of double pleuritis, to which allusion 
has been already made in treating of cavernous respiration in Part I. 

A patient was admitted into hospital apparently in the last stage 
of pulmonary tuberculosis, and died a few days after his admission. 
A single exploration of the chest only was made, which, on the pre- 
sumption of the case being one of advanced tuberculosis, was limited 
to the summit of the chest ; and from the great weakness of the 
patient was confined to the anterior surface. The superior costal 
type of breathing was observed to be remarkably predominant, the 
patient being of the male sex. A clear resonance on percussion with 
tympanitic quality existed at the summit. The respiratory sound was 
loudly developed, the inspiration low in pitch, and followed by an 
expiration shorter, less intense, and lower than the sound of inspira- 
tion. Moreover, at the commencement of the inspiratory act, the 
sound appeared to present a slight amphoric intonation. These were 
the characters on both sides, and upon them, without an elaborate 
examination, as already stated, was predicated the opinion that the 
respiration was cavernous. At the autopsy I expected to find large 
excavations at the apex of both lungs ; but instead of this, there was 
double pleuritis. The chest on both sides was about two-thirds filled 
with liquid, the pleural surfaces being firmly adherent above the level 
of the fluid. A vesicular murmur, thus, highly exaggerated from 



ACUTE PLEURITIS. 549 

the fact that the upper portion of the lung on each side was alone 
available for respiration, and from the great development of the 
superior costal type of breathing, presenting certain of the characters 
of the cavernous respiration, was mistaken for the latter in a case in 
which the general aspect suggested only the idea of advanced tuber- 
culosis. The error of observation was of course due to carelessness 
in physical exploration, and the lesson to be enforced by it is too ob- 
vious to require comment. The case illustrated the law laid down 
by Louis, that double pleuritis generally involves the existence of 
tuberculosis ; for although excavations were wanting, small tubercu- 
lous deposits, not exceeding the size of a small pea, which had not 
advanced to softening, were found in both lungs. 

So far as the amphoric modification is concerned, according to 
the authors above named (Earth and Yalleix), the sound in the so- 
called cavernous respiration incident to pleuritis, does not become 
distinctly amphoric, but only approaches that character. A bron- 
chial respiration with a metallic intonation is an approximation to the 
amphoric respiration. 

During the period of absorption, the expansion of the lung taking 
place in proportion, as the compressing agent is removed, the bronchial 
respiration, if it have existed, disappears, giving place to the broncho- 
vesicular, which gradually assumes more and more of the vesicular 
quality. The respiration, as absorption goes on, becomes audible, 
or resumes its normal characters, progressively from the summit 
downward. Absorption, when the liquid is reduced to a small quan- 
tity, taking place frequently very slowly, absence of respiration with 
dulness or flatness on percussion, often continues for a long time at 
the base of the chest. Feebleness of the respiratory murmur over 
the whole side, characterizes the renewal of the function of the com- 
pressed lung. This continues for weeks or even months. The per- 
manent effects following recovery from pleuritis with large effusion, 
will be noticed under a distinct head in connection with the chronic 
variety of the disease. 

Finally, on the unaffected side during the three periods of the dis- 
ease, but especially during the stage of liquid accumulation, the in- 
tensity of the respiratory murmur is abnormally increased, constituting 
exaggerated or supplementary respiration. 

Of adventitious auscultatory sounds, the bronchial rales are occa- 
sionally heard in cases of pleuritis. Their occurrence is purely acci- 
dental. Bronchitis and pulmonary catarrh coexist with pleuritic 



550 DISEASES OF THE RESPIRATORY ORGANS. 

inflammation only as coincidences. The inflammation does not extend 
to the parenchyma of the lungs, and, consequently, the crepitant 
rale does not belong to the clinical history of the disease. Adventi- 
tious sounds, however, may be developed within the pleural sac, which 
are highly significant. I refer to attrition or friction sounds. If 
patients come 'under observation in the first period, or before much 
liquid accumulation has taken place, a grazing or rubbing sound 
may sometimes be detected over the lower part of the anterior or 
lateral surface, and in. rare instances, during this period, it is audible 
over the greater part of the afi'ected side. The production of the 
sound at this stage must be due, in most cases, to the deposit of fibrin 
on the pleural surfaces. It is possible that the increased vascularity 
of the superficies of the lung, together. with the absence of the usual 
exhalation lubricating the pleura, may be adequate to produce it. 
Walshe gives an instance in which a loud rubbing sound was heard 
over the whole side, and after death, which occurred sixteen days 
from the time when this sign was noted, the pleural surface was found 
to be entirely free from lymph, except over a spot of the size of half a 
crown. The sound is heard in a certain proportion only of the cases 
which are examined anterior to the stage of effusion. The restrained 
movements of the affected side from pain are sometimes insufficient 
for its production, and then it may be developed by inducing the 
patient to disregard the pain and expand the side more fully. It 
would perhaps be detected at this period oftener than it is, ^i^re the 
side to be more frequently examined than is usual, and the explora- 
tions made with care over every point ; for the sign is frequently in- 
termittent, and may be confined to a small space. 

After the accumulation of liquid, and during the stage of effusion, 
a friction-sound is rarely discovered. In exceptional instances it is 
observed, in this period, over the compressed lung. According to 
Walshe, it may occasionally be developed on the back by making the 
patient lie on the face for a little while. It has been observed, also, 
over a considerable area, even when the quantity of liquid is quite 
large. In the latter case it is attributable to the lung having become 
attached, by means of bands or bridles of false membrane, to the 
thoracic wall, which resist the pressure of the fluid, and permit the 
pleural surface to eome into contact over a certain space, notwith- 
standing the amount of effusion. 

It is during the third period, or the stage of absorption, that fric- 
tion-sounds are most apt to occur in pleuritis. The pleural surfaces, 



ACUTE PLEURITIS. 551 

after having been separated by the presence of liquid, are again 
brought into contact, more or less coated with semi-organized lymph. 
It is only during this stage that the rougher sounds, called raspijig 
or grating J are produced. They may have this character, or in the 
third stage, as in the first, only the rubbing and grazing varieties 
may be developed. They are sometimes loud and strong, occasion- 
ally heard at a distance, attracting the patient's notice, and accom- 
panied by a vibratory motion of the parietes perceptible to the touch. 
Their duration is variable. They may last for a very brief period, 
and, on the other hand, they have been known to continue for 
months. 

Friction-sounds by no means constantly attend the stage of absorp- 
tion. The adhesion of the pleural surfaces, which quickly ensues, 
prevent their development. They would probably be more frequently 
discovered than they are, if repeated examinations were made for 
that object ; but at this period of the disease they are generally un- 
important as regards the diagnosis, which has been already made, and 
they are generally sought for merely as a matter of curiosity.* As 
evidence, however, that the pleural surfaces are again in contact, the 
sign is not altogether unimportant at this stage of the disease. Its 
occurrence subsequent to liquid accumulation is, of course, a proof 
of progress having been made in absorption ; but this point is gene- 
rally easily settled by other signs which are more uniformly avail- 
able. 

In conclusion, friction-sounds are chiefly important, in a diagnostic 
point of view, when they are discovered early in pleuritis, because it 
is only at this period that the discrimination of the disease, as a general 
remark, is attended with any difficulty. When they are heard at 
the middle or inferior portion of the chest, or are found to extend 
over the whole side, they are almost pathognomonic. Taken in con- 
nection with symptoms characteristic of pleuritic inflammation, their 
presence establishes the diagnosis. In a negative point of view, 
however, they are of not much importance : that is, their absence is 
not evidence that pleuritis does not exist, owing to the want of con- 
stancy in their association Avith the disease. 

For the characters which distinguish friction-sounds, and by which 
they are to be recognized clinically, as well as -for other practical 

' Bouillaud professes to discover friction-sounds, almost invariably after absorption, in 
cases of pleuritis (Valleix, op. cit.). This may be explained on the supposition tha 
he is accustomed to take greater pains than others in seeking for them. 



Db'2 DISEASES OF THE RESPIEATOKY ORGANS. 

considerations connected ^ith their production, the reader is referred 
to the portion of the chapter, in Part I, on Auscultation in Disease, 
which is devoted to this subject.^ The liability of mistaking a fric- 
tion-sound for a crepitant rale is to be borne in mind, since, practi- 
cally, it might lead to the error of confounding pleuritis with pneu- 
monitis. The occasional occurrence of a pleural friction-sound 
produced by the heart, exclusive of any disease of the latter organ, 
is an item among the curiosities of clinical experience, which is to 
be recollected. The movements of the heart sometimes cause a 
rubbing of the adjacent pleural surfaces sufficient to give rise to a 
sound. Its disconnection from other evidences of pericarditis, and 
association with the other evidences of pleuritis, will prevent mistakes. 

The results of auscultation of the voice are to be taken into ac- 
count in the diagnosis of pleuritis. The results before the stage of 
effusion, if not altogether negative, are not sufficiently marked to 
possess diagnostic importance. They are variable after accumulation 
of liquid has taken place, but are frequently useful in confirming the 
evidence derived from other signs. Over the compressed lung the 
vocal resonance may be abnormally exaggerated ; well-marked bron- 
chophony is sometimes observed, and the occasional occurrence of 
pectoriloquy, under these circumstances, is sufficiently established. 
These vocal phenomena may all be absent, and are present in dif- 
ferent cases with greater or less intensity or prominence. They are 
more marked if, in connection with pleuritic effusion, the lung be soli- 
dified, not by compression only, but by inflammatory consolidation 
or a tuberculous deposit. When strongly marked they afford pre- 
sumptive but not positive evidence of solidification, in addition to the 
condensation due to the pressure of liquid effusion. If not strongly 
marked, they are significant of condensation, or some abnormal con- 
dition, on the left more than on the right side, owing to the normally 
greater vocal resonance on the right side. This remark is applicable 
to exaggerated vocal resonance only, not to bronchophony and pecto- 
riloquy. 

These vocal signs are generally limited to the summit of the chest, 
and confined to an area circumscribed in proportion to the space 
occupied by the compressed lung. They are oftener discovered over 
the scapula and in the interscapular region behind, owing to the 
usual situation of the compressed lung in cases of large effusion. 

Over the space occupied by liquid, the vocal signs which have been 

^ Vide, page 242. 



ACUTE PLEUKITIS. 553 

named are usually wanting. A contrast as regards vocal resonance 
between the upper and lower portion of the affected side, when the 
percussion-sound is at the same time observed to be flat below, and 
more or less sonorous above, is pretty conclusive evidence of the pre- 
sence of liquid ; for if the relative flatness at the inferior portion of 
the chest proceeded from greater solidification of lung, the vocal 
resonance would be expected to be more marked than at the superior 
portion of the chest, where a certain amount of resonance is elicited 
bj percussion. 

In like manner, a contrast between the two sides inferiorly, con- 
sisting in the presence of vocal resonance on the healthy side, and its 
absence on the affected side, affords strong proof of effusion. Here 
the allowance for a normal disparity between the two sides, is the re- 
verse of that to be made when it is a matter of question as to solidifi- 
cation of lung at the summit. If the flatness on percussion be on the 
right side, and the greater vocal resonance on the left side, the proof 
of effusion in the right pleura is stronger than it would be were the 
left side the one affected. 

But auscultation furnishes a vocal sign deemed by Laennec pathog- 
nomonic of pleuritic effusion, and still considered by many as highly 
significant. I refer to the sign called ^gofliony. A singular dis- 
crepancy of opinion exists among different observers as regards the 
frequency with which this sign is discoverable in pleuritis, the extent 
of its diffusion, and its diagnostic importance. This discrepancy 
may perhaps in part be accounted for on the supposition that the term 
segophony is used by some in a more comprehensive sense than by 
others. It may be applied to slight modifications of the transmitted 
voice, or it may be restricted to instances in which the tremulousness 
and acuteness are sufficiently distinct to constitute at least some ap- 
proach to the bleating cry of the goat, or the other sounds to which 
it has been compared.^ Without dwelling on the subject here, I 
shall refer the reader to the remarks under this head contained in 
the chapter on Auscultation in Disease, in Part I.^ That aegophony 
is properly regarded as a physical sign distinct from bronchophony 
and pectoriloquy, is unquestionable. That it is highly significant 
of pleuritic effusion, when well marked, appears to be sufficiently 
established. I am free to confess, however, my inability to speak of 

1 The distinction between transmitted voice and transmitted speech is to be kept in 
mind. The former is bronchophony ; the latter pectoriloquy. 

2 Vide page 267. 



o5-i 



DISEASES or THE RESPIRATORY ORGANS. 



? 



its value from much practical acquaintance with it ; but this is per- 
haps owing to the fact that I have not made it the subject of much 
clinical study, repeated disappointments in seeking for it having led 
me to distrust its availability. The reader will, of course, attach 
due weisht to this confession in connection with the remarks in Part 
I, to which he is referred. 

Inspection and mensuration furnish striking and valuable signs in 
pleuritis. Under the influence of pain the movements of the affected 
side are so far restrained by the will, as to give rise to a perceptible 
diminution in expansion by the inspiratory act, and on measure- 
ment, the size, as also the range of motion, may be found slightly 
reduced during the first period. The voluntary restraint of motion is 
especially apparent in the act of coughing. These results give place 
to others more marked and distinctive in the second stage. The 
lower part of the affected side, in proportion to the amount of liquid 
accumulation, becomes dilated, and the inferior costal movements, with 
respiration, are lessened or arrested. The intercostal spaces exhibit 
less depression, and are generally not so deeply indented in the 
inspiratory act, as on the opposite side. 

Accumulating in still larger quantity, the liquid meets with more 
resistance from the condensed lung than from the thoracic parietes, 
and the latter accordingly yield to the dilating force. The affected 
side becomes conspicuously enlarged, and its range of motion in re- 
spii-ation proportionally limited. It is dilated frequently to the fullest 
extent of voluntary expansion, or even beyond this limit, and hence 
remains motionless, while the movements of the opposite side are 
supplementarily increased. The intercostal depressions are now 
abolished, and a slight convexity between the ribs may in some in- 
stances be apparent. Over the lower and middle portions of the 
side the ribs are abnormally separated, while at the summit they 
converge more than is natural. The obliquity in the direction of 
the ribs is diminished. Approaching to a horizontal line, their 
angular union with the costal cartilages is no longer obvious. 
Measui'ement of the semicircular circumference, of the vertical 
distance from the base to the summit, and, by means of calli- 
pers, of the antero-posterior diameters, shows an increase of size 
in all directions. The nipple is somewhat elevated, and is removed 
at a greater distance than on the opposite" side from the median line. 
On a posterior view a marked contrast is observed between the two 
sides in the elevation of the scapula with the act of inspiration. 



ACUTE PLEITRITIS. 555 

These are the phenomena, determined by inspection and mensuration, 
which denote a very large accumulation of liquid within the pleural 
cavity. Occasionally presented in acute pleuritis, they are much 
oftener observed in the chronic form of the disease. 

In the progress of absorption of the effused fluid, a series of changes 
take place, the reverse of those which characterize progressive accu- 
mulation of fluid. The enlargement decreases ; the bulging inter- 
costal spaces become flattened ; the divergence of the lower ribs 
diminishes, and they assume a more oblique direction ; the nipple 
falls, and its distance from the median line is lessened ; some degree 
of expansive movement is perceptible, taking place more slowly than 
on the opposite side, and depression of the side at the summit is apparent. 
With these changes the affected side may be still nearly filled with 
liquid. Finally, when absorption of the whole or a greater part of 
the liquid is effected, the alterations in size, motions, and relations 
of the different parts are frequently still more marked. The side 
becomes contracted in every direction. It is obvious to the eye at 
the lower, as well as at the upper part, when the chest is examined 
either behind or in front. Mensuration with the inelastic tape, or with 
callipers, shows this to be the case. Lateral curvature of the spine 
is apt to occur, the concavity looking toward the affected side. The 
shoulder (with occasional exceptions) is depressed ; the interscapular 
space is narrowed; the lower angle of the scapula projects from the 
thoracic wall ; the lower ribs approximate more than on the opposite 
side ; the nipple falls below the level of its fellow, and is nearer the 
median line ; the range of motion in the acts of respiration is greater 
than before, but still limited on comparison with the healthy side. 
These changes always succeeding chronic pleuritis with large effusion, 
but not so constant after the acute variety, in amount bear a certain 
proportion to the extent to which the side has been previously ex- 
panded ; in other words, to the quantity of liquid effusion which has 
existed. They are, however, also dependent on the condition of the 
compressed lung as regards its ability to become expanded as the 
pressure is removed ; and since this condition is affected by other 
circumstances than simple condensation, viz., by the adhesion of the 
pleural surfaces, and the organization of lymph deposited upon it, the 
contraction of the side resulting from pleuritis will differ in different 
cases in which the quantity of effused liquid was about the same. 

Contraction of the affected side after pleurisy will be likely either 
to be wanting entirely, or to be less marked and less persisting in 



556 



DISEASES OF THE RESPIRATORY ORGANS. 






proportion as the effusion and its removal by absorption have been 
rapid. For this reason, assuming an equal amount of accumulation, 
the changes first mentioned characterize chronic rather than acute 
pleuritis. But they are more apt to follow chronic pleuritis for 
another reason, viz., the quantity of liquid effused is usually much 
greater in this variety of the disease. The rapidity with which ab- 
sorption goes on in acute, as well as in chronic pleuritis, varies much 
in different cases. It is not uncommon to observe a very great reduc- 
tion within a few days or even hours ; but after the quantity is re- 
duced to a certain point, the removal is always effected more slowly. 
The side may be obviously depressed at the summit or middle third, 
when it is still enlarged at the lower part, as shown by mensuration. 
As regards permanent effects on the chest, there may not be any ob- 
vious disparity after the lapse of weeks or months succeeding an attack 
of the acute form, even when the quantity of liquid effusion was con- 
siderable, and a certain amount of contraction was evident immedi- 
ately after recovery. It is otherwise, however, with cases of chronic 
pleuritis ; and I shall refer to this point under the head of the latter. 

Examinations of the chest by inspection and mensuration in 
cases of pleuritis, are not only useful in order to ascertain the exist- 
ence or non-existence of either dilatation or contraction, but that the 
progress of the disease may be watched from day to day, as regards, 
in the first place, the increase in the accumulation of liquid, and in 
the second place, its decrease by absorption. In cases in which the 
affected side is filled with fluid and the thoracic wall expanded, per- 
cussion and auscultation do not afford the means of determining from 
day to day variations in the quantity of effusion. Inspection and 
mensuration are available for this object, and the results may be im- 
portant in determining the practitioner either to continue or to change 
his therapeutical measures. 

Much interesting and important information is frequently derived 
from the employment of palpation in cases of pleurisy. In the first 
period it furnishes evidence of tenderness to the touch, and also that 
the soreness is not in the inteo-ument but in the intra-thoracic struc- 
tures. The pain produced by manual examination of the affected side 
is not superficial and occasioned by mere contact of the hand, as in 
some instances of hypersesthesia of the surface, but is more deeply 
seated and proportionate to the degree of pressure made. 

But it is more especially during the second and third periods that 
this method of exploration furnishes useful facts. The effect of an 



ACUTE PLEUEITIS. 557 

accumulation of a considerable quantity of liquid is usually to abolish, 
the normal vocal fremitus on the affected side over a space correspond- 
ing to that occupied by the effusion. And at the same time^ in some 
instances, the fremitus is increased over the condensed lung above 
the level of the liquid. Marked diminution or suppression of the 
normal vocal fremitus may thus constitute a physical sign of liquid 
effusion, the more significant, because over consolidated lung the fre- 
mitus is frequently exaggerated. It is obvious that to become a sign 
of effusion, absence of fremitus must be associated with other signs; 
and it is to be borne in mind that in many persons the normal fre- 
mitus is greater on the right than on the left side. If flatness on 
percussion at the lower part of the chest coexists with absence of 
fremitus, while on the opposite side there exists vesicular sonorous- 
ness with a fremitus more or less marked, the evidence is strong that 
the flatness is due to effused fluid rather than solidified lung. And inas- 
much as in some persons a fremitus exists naturally on the right side 
and not on the left, the evidence is stronger when the effusion is into 
the right pleural sac ; in other words,, flatness on percussion with 
absence of fremitus, indicates effusion more positively on the right 
than on the left side, making due allowance for the fact that this com- 
bination of signs may be produced by the encroachment of an en- 
larged liver on the thoracic space. 

Palpation furnishes still other facts. By this method better than 
by inspection are ascertained the most important of the displacements 
of intra-thoracic parts which take place in the second and third 
periods of pleuritis with large effusion. An accumulation of liquid in 
the left pleural sac removes the heart from its normal situation. This 
may occur, and to a great extent before the thoracic parietes become 
dilated. Occasionally the heart is pushed downward in a direction 
toward the epigastrium, but in the great majority of instances it is 
carried upward and outward in a diagonal line extending from the 
prsecordia to the right shoulder. It is found, as the fluid accumu- 
lates, to be situated beneath the sternum, and at length its pulsa- 
tions may be felt and frequently seen on the right side, and some- 
times beyond the nipple."" If, on the other hand, the effusion be 
within the right pleural sac, and the accumulation be large, the heart 

• Alteration of the heart-sounds, even with the greatest amount of displacement, is 
very rarely observed. A bellows' sound is occasionally developed, which disappears 
when the heart resumes its normal situation. The existence of a murmur, under 
these circumstances, therefore^ is not proof of cardiac disease, even excluding anaemia. 



558 DISEASES OF THE RESPIEATORY OEGANS. 

is displaced in a direction upward and outward toward the left axilla. 
If the impulse of the dislocated heart can neither be seen nor felt, 
which must be rarely the case except when it is beneath the sternum, 
the sounds of the organ, as determined by auscultation, must be the 
guide to its abnormal situation. Its return to the prsecordia is evi- 
dence of the progress made in the absorption of the effused fluid. 
In some instances it has been observed to regain its normal situation 
in the course of a few days and even hours, showing very rapid 
diminution in the quantity of effusion. It does not, however, always 
return to its normal situation when the force which in the first in- 
stance pushed it out of place is no longer operative. It may be 
detained in its abnormal position by morbid attachments. And it is 
a curious fact that the suction-force developed by the absorption of 
the effused liquid may not only prevent the organ when displaced, 
from again resuming its position in the prsecordia, but it may prove 
an active cause of displacement. In cases of copious effusion within 
the right pleura, after absorption, the heart has been found to be 
drawn into the right side ; and subsequent to the removal of an 
effusion in the left pleura sufficient to displace the heart to the right, 
it may at length occupy a position to the left of the prgecordia. 

Displacement of the diaphragm is another of the mechanical effects 
of a large effusion. This, according to the observations of Stokes, 
may take place suddenly, so that the fluid finding additional space 
in this direction, the semicircular circumference of the affected side 
may possibly be diminished, and the line of percussion-flatness on the 
chest lowered, although the quantity of liquid is increasing. The 
depression of the diaphragm of course carries downward the subjacent 
organs. On the right side this is evidenced by the lower situation of 
the liver. Under these circumstances, owing to the convexity of its 
upper surface and the convexity of the depressed diaphragm, a sulcus 
or furrow is sometimes apparent between the lower margin of the 
chest and the point at which the anterior surface of the liver projects 
against the abdominal wall. Again, after absorption, the diaphragm 
is drawn upward with the subjacent organs above the point at which 
it rises normally within the chest ; and the liver on the right side, or 
the stomach and spleen on the left side, are found to ascend higher 
than in health. The latter changes, however, are ascertained by 
percussion rather than by palpation, and the same remark is appli- 
cable to lateral displacement of the mediastinum, to which reference 
has been already made under the head of Percussion. 



ACUTE PLEURITIS. 559 

Owing to the abolition of the intercostal depressions during the 
stage of effusion, the affected side offers to the touch, as well as to 
the eye, an unnaturally regular and smooth surface, which is after- 
ward lost when contraction of the chest takes place, and finally, in 
some instances, the presence of liquid in the pleural sac may be 
made to give rise to a sense of fluctuation appreciable by palpa- 
tion. This may be discovered occasionally, by applying the left 
hand over the affected side at the base, and percussing the ribs with 
the pulpy portion of the fingers of the right hand. In thin persons, 
peripheric fluctuation, as it is called, is oftener available. If a finger 
be applied over an intercostal space, and a light, quick percussion- 
stroke be made at a short distance in the same space, the peculiar 
shock significant of the presence of fluid may be appreciable. 

I ' Diagnosis. — -Certain of the symptoms of acute pleuritis are some- 
what distinctive. Pain is usually a prominent symptom during the 
first period. It is sharp, lancinating in character, felt generally with 
the act of inspiration, and its severity increasing with the progress 
of the act, renders the latter interrupted, and shortens its duration. 
In these respects, however, it does not differ from the pain in pleu- 
ralgia. It is referred oftenest to the lower part of the affected side 
laterally, and in front ; sometimes extending to the back or over the 
whole side, and occasionally felt exclusively on the opposite side or 
in the abdomen. It diminishes as effusion takes place, and at length 
ceases to be prominent or disappears. The respirations are multi- 
plied at first, by way of compensation for their incompleteness in con- 
sequence of pain, and afterward from the interruption of the function 
of the lung on the affected side due to its compression. Dyspnoea 
occurs in only a small proportion of cases, which are characterized 
by rapid and copious effusion. Cough is sometimes, but rarely, absent. 
It is usually dry, excited spasmodically, and partially suppressed to 
avoid the pain which it occasions. The significance formerly attached 
to position or decubitus, at different stages of the disease, appears to 
be in a great measure disproved. 

With an adequate knowledge of the physical signs which belong to 
acute pleuritis, the diagnosis, certainly in the great majority of cases, 
is sufficiently easy. It presents difficulties only to those who do not 
qualify themselves to employ physical exploration. By those who 
rely exclusively on the diagnostic symptoms, it is not infrequently 



560 DISEASES or THE EESPIEATORT OEGAXS. 

confounded with pleurodynia, intercostal neuralgia, and pneumonitis. 
Instances illustrating these errors of diagnosis hare repeatedly fallen 
under my observation. It will suffice to point out the more impor- 
tant of the circumstances involyed in the differential diagnosis from 
the affections just named, commending to the student the study of the 
physical signs of the disease until they become perfectly familiar. 

In pleurodynia and intercostal neuralgia, the physical phenomena 
which attend the march of acute pleuritis are wanting. The absence 
of these phenomena enables us either to exclude pleuritic inflamma- 
tion, or to establish its existence. In a purely neuralgic or rheumatic 
affection, however, diminished expansion of the affected side, with 
slight reduction in size, feebleness of the respiratory murmur and 
perhaps relative dulness may be present, these results being due ex- 
clusively to the restrained movements from pain. The affected side 
may also be more exquisitely tender on pressure than when pleuritic 
inflammation exists. Guided alone by the results of exploration, for 
a brief period after the attack, the discrimination might involve 
doubt. The existence of marked febrile movement is an important 
point at this period. Symptomatic fever constantly accompanies 
acute inflammation of the pleura, while it attends pleurodynia and 
intercostal neuralgia only as a coincidence. If a friction-sound be 
discovered which we are satisfied is pleural in its origin, it renders 
the diagnosis quite positive. But the constancy of this sign cannot 
be relied upon, and, indeed, it is rarely discovered in the early stage 
of pleuritis. Its absence, therefore, is not proof that a doubtful 
affection is either neuralgic or rheumatic. 

But the occasion for hesitancy usually exists for a brief period 
only. The occurrence of serous effusion, if the disease be acute 
pleuritis, gives rise to positive signs, which render certain the presence 
of something more than a neuralgic affection or an attack of rheuma- 
tism seated in the thoracic walls. And, on the other hand, the absence 
of the physical evidence of effusion authorizes an exclusion of acute 
pleuritis. A fact, however, observed by Louis and others, is impor- 
tant to be borne in mind, viz., an attack of acute pleuritis is occa- 
sionally preceded by a neuralgic affection of the side in which the 
inflammation becomes afterwards developed. Two instances illus- 
trating this fact have come under my observation, in which the 
patients experienced acute pains in the side, without febrile move- 
ment, or any of the physical signs of pleuritic inflammation, for several 



ACUTE PLEURITIS. 561 

days before an attack of the latter which was signalized by a chill, 
increased pain, and febrile movement. 

In the differential diagnosis from acute pneumonitis, we have to 
distinguish between the physical signs belonging respectively to this 
affection and acute pleuritis. In pneumonitis there occurs, often 
within a short space of time, marked dulness on percussion over a 
certain portion of the affected side. If the upper lobe be first in- 
flamed, the dulness will be found at the summit and on the anterior 
surface, while the posterior surface below the scapula is resonant on 
percussion. The reverse obtains in acute pleuritis after effusion has 
taken place. But in the majority of instances, pneumonic inflamma- 
tion attacks the lower lobe, and in the lobar form invades speedily the 
entire lobe. The dulness will then be found to be bounded on the 
chest by a line pursuing the direction of the interlobar fissure, and 
not to vary with the change of position of the patient, the latter 
-being observable in a certain proportion of the cases of pleuritis with 
effusion. The liquid in pleuritis generally accumulates rapidly, and 
the flatness on percussion is found to extend over a larger portion of 
the affected side than in cases of pneumonitis. In certain cases of 
pneumonitis, it is true, the entire lung may become solidified ; but in 
these cases a single lobe is first attacked, and at a subsequent period 
the inflammation crosses the interlobar fissure, and invades the other 
lobe. If such cases are under observation from the beginning, the 
length of time occupied by the extension of dulness over the chest 
distinguishes the disease from acute pleurisy. 

Other differential points are not less distinctive. The presence of 
a considerable quantity of liquid in the pleural cavity gives rise to 
flatness on percussion. Solidification of lung produces only dulness, 
and, in a certain proportion of instances, the vesicular is replaced by 
tympanitic sonorousness, more or less marked. The dulness from 
solidified lung is accompanied, generally, by a well-marked bronchial 
respiration, frequently intense, metallic, and appearing to be de- 
veloped near the ear. The flatness from the accumulation of liquid 
is Uvsually associated with suppression of respiratory sound ; or, if a 
bronchial respiration be discovered, it is comparatively feeble and 
distant in the great majority of instances. Increased vocal resonance, 
bronchophony, and occasionally pectoriloquy, are signs belonging to 
solidification ; their absence is the rule over liquid effusion. j5]go- 
phony is occasionally heard over the latter, and rarely over the former. 



562 DIBEASEE 01 IZI EE SFIE AT Ox. Y OHQAlsS. 

JToal f iP Hiiitm is often exag^ziiiri "bj solidifieation, and :: li _:::- 
Ibhed by the preseiiiee of Hqmd. 

An accmsalaiiim of a large qaamlstj of liquid in tiie pleural cavity 
podnees comffldeirable or great ^nlaTgement of tlie aSected side, and 
llie inliQVos: .. ititSs: -__^ _l pneumonitis, tlie enlarge- 
m filial;. Mid t- t :_ : r : . : i : i . remain. Displacements 

i£ ^bsheaa% diap"-: : _ -i . : l ;. '-_::_.:.___ __^, are marked effects of 
et^iiiNis liqnid dBDi.;i., il.'. :_r7 ; ::iir Lnt to a slight extent as re- 
sobs isi eolidifiiealion. 

MuteoTcr, a, sjirj::- ::r5 n ?:Vi: s'.rzost patio^omomc of aeate 
pnearaaiiiiiB are w^^l : _ _ : .1 1 : :. . ^ _. :::s, viz., the rasty cxpectora^ 
tiom snd the csr^it . : 

Tmri ' _. : . II r : " : : ' ' ""J f ? as regards tlie plijsical 
to :_ - : : irrasted, can alone c<Hisii- 

tolesaSciraitgnNir . „ j _ng the differential diagno^ 

V<st example, in son ; . 1 ? ^^^^ ©Snaon, a feroncLial 

rei^iralagii is foioi i : i:te affected side ; and, 

en the other hand. 1 ; ; _. r : r ^ :. from pnenmonitis, 

absence of res]'::: :7 e. Attention, ho w- 

r, to other ■ ^-t^ „ : .. ___ ^_^:ino^ will develope 

ipAe data fo : _ r . . _ „ 



SUMMAS-a <j± jcHTeiOAL cIGXS £Ei>OS\irSG TO ACUTE PLEIJB.ITIS. 

Fir^ Period^ wiz^prwr t& Ajccmmidatmn &f Uqmd. — ^Moderate or 
dimimrtion of TeBeolar i^esoiaance^ or daJneBS on percussion. 
Fedble and iiiteniq»ted Tt^irat<»j nmimiir. ]No altamtion in vocal 
TCStmanee or ficmitiis. Diminifhed expan^iKitj of tlie affected side. 
Tend^ne^ <hi pir^SDre. Oeea^onallj a ^raxiiig (ff mhbing frictioor 
soond. 

Ses&nd P&rwd^ ©r Stjoge ^f AscumuLatwn of Liqmd. — ^Flatness 
<Hi perei^im fmm the base of the diest, extending npwaid, more or 
l^s^ over tlie affeded ede; dBmini^ed elastidty of thora.cic pariet^ 
and seiKe of re^stanee notabfy increased. Tympanitic sonoronsness 
Taryiog in degree aboTe the level of the liqnid, frequently exceeding 
in iLTrnsit" ']^T smndonthe (^po^te side. Amphoiic ©r metallie 
n. :• i_£ . i : : ; L : : : 5 rnanoe at the ^amoit, son&etiM^ stron^y marked, 
and : :: 5 . 1 ~ ; acted-metal Taiietj of eonnd diseovered. The 

lindfts oi £ : f 5 in proporttaxM of cases, :&iimd to vary "when 

the paliei:: : : i _i_ t i _z ^ . -nt pt^ilioBS. The Satne^ sometimes fomid 



ACUTE PLEURITIS. 563 

to extend, in front, on the opposite side, even beyond the sternum, 
in consequence of lateral displacement of the mediastinum. Respi- 
ration often suppressed below the level of the liquid effusion ; bron- 
cho-vesicular or bronchial over the compressed lung. A bronchial 
respiration sometimes diffused over the chest, but usually feeble and 
distant, except at the summit. In the latter situation generally dis- 
coverable either in front or behind, oftener the latter, varying in 
different cases as respects intensity and the area over which it is 
heard. Sounds of heart transmitted to distant parts through the 
mass of liquid. Friction-sounds occasionally heard in this stage. 
Increased vocal resonance, sometimes bronchophony, and, as a rare 
phenomenon, pectoriloquy, discovered at the summit of the chest on 
the affected side. All these vocal signs may be absent at the summit, 
and they are all absent, as a rule, over the portion of the side occu- 
pied by the liquid, ^gophony present in a certain proportion of 
cases at a particular and usually a transient period in this stage. 
Generally, when present, limited to the neighborhood of the inferior 
angle of the scapula behind, and to a zone extending from this point 
to the anterior part of the chest ; but, exceptionally, in some instances 
diffused over the whole side. Dilatation of the affected side, com- 
mencing below and extending, in some cases, over the entire side ; 
the intercostal depressions effaced, and various alterations in the re- 
lations of the external component parts of the thoracic parietes. 
Dislocation of the heart, and depression of the diaphragm, with sub- 
jacent organs, from the pressure of the fluid. Unnatural regularity 
and smoothness of the surface of the affected side. Fluctuation per- 
ceptible to the eye and to the touch in some instances. Comparative 
immobility of the affected side. Abolition of vocal fremitus below 
the level of the liquid. Increased respiratory movements and ex- 
aggerated vesicular murmur on the healthy side. 

Third Period^ or Stage of Absorption. — Vesicular or vesiculo- 
tympanitic resonance on percussion, developed first at the summit 
and gradually extending downward, but, relatively to the opposite 
side, persisting dulness. Flatness continuing at the base. Respira- 
tion feeble and broncho-vesicular, progressively developed from above 
downward, gradually assuming the normal vesicular character. Sup- 
pression at the lower part of the affected side. Vocal resonance and 
fremitus absent at the lower part of the affected side, and either 
wanting or more or less marked above, ^gophony sometimes dis- 



564 DISEASES OF THE EESPIEATORY OEGAXS. 

covered in this stage. Depression at the summit of the chest, and 
afterward frequently, if the effusion have been large, marked con- 
traction of the whole side, with changes in the relations of the differ- 
ent external component parts of the thoracic parietes. the reverse of 
those which have previously existed indicating dilatation. L-regu- 
larity of the surface of the affected side. Limited expansive move- 
ments. Friction-sounds much oftener discovered in this stage than 
in the first or second, and in this stage frequently grating or rasping, 
accompanied sometimes by tactile fremitus. Displacement of the 
heart from the previous pressure of the liquid, or taking place as an 
effect of absorption. Abnormal elevation of the diaphi^agm and sub- 
jacent organs, after very large effusion, and lateral displacement of 
the mediastinum toward the affected side. 



Chronic Pleueitis. 

Chronic pleuritis with copious serous effusion is entitled, clinically, 
to be considered as an affection distinct from acute inflammation of 
the pleura, since, it rarely follows or is preceded by the latter. In 
the majority of cases, the inflammation is subacute from the first. 
The anatomical conditions, however, so far as concerns their relations 
to physical signs, are essentially the same as in acute pleuritis after 
an accumulation of liquid has taken place. The chief point of dif- 
ference relates to the quantity of effusion. In chronic pleuritis with 
copious effusion, the quantity commonly attains to an amount which 
is only occasionally observed, in the acute variety. The clinical his- 
tory of the former is therefore characterized by the phenomena to 
which a large accumulation gives rise. When cases of chronic pleu- 
ritis present themselves to the physician, they exhibit one of two 
phases of the affection ; and it suffices for practical convenience to 
consider each phase as a distinct period or stage. The two periods or 
stages correspond to the second and third of acute pleuritis. The 
first period or stage of the latter is, in fact, wanting in chronic pleu- 
ritis. The first period, or stage, will. then, continue so long as the 
liquid in the pleural sac is accumulating, or remains stationary. 
This may be termed the stage of accumulation. The second period 
or stage extends from the time when the liquid begins to diminish, 
till its removal is effected ; and this may be called the stage of ab- 
sorption. The first period is frequently of brief duration, but it 
varies in this respect considerably in different cases. The second 



CHRONIC PLEURITIS. bQ5 

period is usuallj mucli longer, being rarely limited to a few weeks, 
and often embracing many months. 

Although less frequent in its occurrence than the acute variety, 
chronic pleuritis is not a very rare affection. It was remarked by 
Dr. Hope that "there is no class of affections more habitually over- 
looked by the bulk of the profession than this;" and the previous 
histories in the cases that have fallen under my observation have 
afforded evidences of the correctness of the remark.^ This fact 
renders the diagnosis a subject of importance. The fact, however, 
is significant, not of intrinsic difficulties in the way of discriminating 
the disease, but of the extent to which physical exploration of the 
chest is neglected. As regards physical signs and the points 
involved in the diagnosis, they have, for the most part, been em- 
braced in the consideration of acute pleuritis. Inasmuch, however, 
as familiarity with the phenomena attained by exploration and their 
combinations is only to be acquired by repetition, a recapitulation of 
these signs and diagnostic points in the present connection will not 
be disadvantageous to the student. 

JPhysical Signs. — A patient with chronic pleuritis who comes under 
observation while the serous effusion is either accumulating or remains 
stationary at the highest point of accumulation, will be found, in the 
great majority of cases, to present the physical evidence of a sufficient 
cjuantity of liquid in the pleural sac to fill the affected side, compress- 
ing the lung into a small space, and frequently the phenomena inci- 
dent to enlargement and displacement of other intra-thoracic organs 
are superadded. 

The percussion-sound is flat from the base of the chest upward 
over the whole or greater part of the affected side. A tympanitic 
resonance may be discovered at the summit, with perhaps an ampho- 
ric intonation. The want of elasticity of the thoracic parietes and 
sense of resistance felt in percussing, are marked. 

In the majority of cases, at least in adults, all respiratory sound 
is suppressed over the greater part, and sometimes over the whole of 
the affected side. In a small proportion of instances, in adults, a 
bronchial respiration may be perceived more or less diffused. It is 
feeble, and conveys the impression of distance, except at the summit. 
In the infra-clavicular region, in a certain proportion of cases ; in 

■• Vide Clinical Report on Chronic Pleurisy, based on an analysis of forty-seven cases, 
by the author, 1853. 



566 DISEASES OF THE RESPIRATORY ORGANS. 

the upper scapular region, in a larger proportion ; and in the inter- 
scapular region commonly, a bronchial respiration may be discoTered, 
more or less intense, and seemingly near the ear. It yery rarely, in 
either of these situations, has that intensity, acuteness, and metallic 
tone which belong frequently to the bronchial respiration due to lung 
solidified by tuberculous, and still more by inflammatory deposit. 
On the healthy side the respiratory murmur is intensified but vesi- 
cular, distinguished as exaggerated, puerile, supplementary, or hyper- 
vesicular. Greater vocal resonance, and sometimes bronchophony, 
may be found on the affected side in the interscapular space, and less 
frequently in the upper scapular and infra-clavicular regions. Else- 
where than at the summit, these vocal signs are wanting, ^gophony 
is an event of rare occurrence. 

Inspection discovers comparative or positive immobility of the side 
affected ; and on the opposite side the respiratory movements are 
manifestly increased. The affected side may remain quite motionless, 
even when the respirations are forced, or there may be a slight and 
tardy elevation of the ribs. In proportion as the side is but little 
affected by forced respiration, it is usually enlarged in size. It is 
distended to quite or even beyond the extreme limit of a voluntary 
expansion. The ribs are raised, and they approach to a horizontal 
direction. The lower ribs diverge and the upper converge. The 
intercostal depressions are effaced, and there may be bulging between 
the ribs. The nipple is raised, and removed at a greater distance 
from the median line than that on the opposite side. The side pre- 
sents an unnaturally regular and smooth appearance. Slight oede- 
matous infiltration beneath the integument of the affected side is 
sometimes observed. Semicircular measurements with the inelastic 
tape, applied just below the nipple and the lower angle of the sca- 
pula, show an increase of size, varying, of course, not only in differ- 
ent cases, but perhaps at different periods of this stage, the maxi- 
mum being about two inches. Diametrical mensuration with callipers 
will also show enlargement between different points. 

Palpation, in conjunction with percussion and inspection, shows dis- 
placement of movable parts within the chest, in addition to the com- 
pression and elevation of the pulmonary organs. The heart, if the 
left side be affected, is pushed to the right, carried beneath the ster- 
num, and frequently transferred to the right side, being found to 
pulsate sometimes even beyond the nipple. If the effusion be in the 
right side, it is elevated and carried in a diagonal direction to the 



CHRONIC PLEURITIS. 567 

left. The mediastinum is displaced laterally, and flatness on percus- 
sion is sometimes discovered not only over the sternum, but for a little 
distance beyond on the opposite side. The dislocation of the heart 
will, of course, give rise to dulness over its new situation. Depres- 
sion of the diaphragm with the viscera in contact with its inferior sur- 
face, occasions on the left side extension downward of flatness from the 
presence of liquid ; and on the right side hepatic flatness to an abnor- 
mal extent below the ribs, a tumor-like projection caused by the ante- 
rior surface of the liver, and a sulcus above due to the convexity of its 
upper surface. This sulcus, as remarked by Stokes, may after a 
time be lost, before absorption takes place, in consequence of the 
convexity of the liver being diminished by pressure. 

Fluctuation in the intercostal spaces may sometimes be discovered. 

The vocal fremitus natural to the afiected side is abolished. 

During the second period, the physical signs will present, at suc- 
cessive explorations, repeated at intervals of some duration, variations 
in degree rather than in kind, according to the rapidity with which 
the efi'used fluid is removed. The changes may consist in a gradual 
return to the normal condition as respects the size, mobility, and 
relations of the difi'erent anatomical parts, internal and external, of 
the affected side. But it is very rarely if ever the case that a normal 
condition is recovered, and the natural symmetry of the chest left 
unimpaired. As the quantity of liquid diminishes, the enlargement 
of the side decreases, and, at length, it falls within its natural dimen- 
sions. Depression of the upper third in front is first observed. This 
frequently takes place while the semicircular measurement still shows 
enlargement. Finally, contraction universally of the affected side is 
a uniform result when the liquid is completely absorbed or reduced 
to a small quantity. The various phenomena, ascertained by inspec- 
tion, which are incident to contraction of the chest after the removal 
of pleuritic effusion, in general terms, are the reverse of those which 
characterize dilatation. They have already been mentioned in con- 
nection with acute pleuritis, and will again be reproduced under the 
head of the Retrospective Diagnosis of Chronic Pleuritis: they need 
not, therefore, be here enumerated. 

But before marked contraction of the chest takes place, the dis- 
placed intra-thoracic organs, especially the heart, retrograde toward 
their normal situations. And as regards the final disposition of these 
organs, certain changes are liable to succeed chronic pleurisy, which 
have been already noticed, inasmuch as they occasionally follow the 



568 DISEASES OF THE RESPIRATORY ORGANS. 

acute variety of the disease ; and these also will be recapitulated pre- 
sently. 

Percussion-resonance, in proportion as the compressed lung under- 
goes expansion, becomes deyeloped at the upper part of the chest, 
and extends downward. The affected side over the space occupied 
by the expanded lung, however, in most instances yields a dull sound 
compared with the resonance of the healthy side : and if sonorous- 
ness be marked, as is sometimes the case, it is vesiculo-tympanitic in 
quality. The respiratory sound becomes developed, extending lower 
and lower, but relatively feeble, and with more or less of a broncho- 
vesicular character. The vocal resonance may be greater or less 
than on the healthy side. The same is true of vocal fremitus. 
Friction-sounds are frequently discovered during this stage. They 
are to be sought for over the middle and lower thirds in front, late- 
rally, and behind. They are often rough and loud. I have known 
an instance, already referred to, in which they attracted the atten- 
tion of the patient, continuing when he was able to be up and out 
of doors. They may be accompanied by tactile fremitus. They 
persist in some instances for a long period. I have noted their ex- 
istence in a case ten months after the date of the commencement of 
the disease. 

-^gophony is sometimes discovered during the progress of absorp- 
tion. 

The period occupied by the successive and progressive changes indi- 
cating the diminution and removal of the liquid effusion in chronic 
pleuritis, as already stated, is variable, but in most cases it extends 
over several months. 

Diagnosis. — So far as the symptomatology of the disease is con- 
cerned, irrespective of the physical signs, chronic pleuritis is often 
remarkably latent. Excluding the small proportion of cases in which 
it is preceded by acute pleuritis, the development of the affection is 
very rarely attended by severe pain, and frequently this symptom is 
entirely wanting. In obtaining the previous history, the fact of pain 
having existed would often escape notice without careful inquiry, the 
attention of the patient being at the time scarcely attracted to it, and 
its occurrence forgotten. When cases come under observation after 
the disease has existed for several weeks, absence of pain is the rule. 
Cough and expectoration are sometimes wanting, and are rarely pro- 
minent. As a rule, these symptoms do not precede the development 



CHRONIC PLEURITIS. 569 

of chronic pleuritis except they depend on antecedent pulmonary 
tuberculosis. When cough is present it is generally either dry or 
accompanied by a small expectoration, which consists of mucus more 
or less modified. The sudden occurrence of a copious sero-albumi- 
nous or puruloid expectoration, continuing for a greater or less period^ 
indicates ulcerative perforation of the pleura commencing within the 
sac, and establishing a communication with the bronchial tubes. This 
accidental event gives rise to pneumo-hydrothorax. The respirations 
are usually increased in frequency, but to this rule there are excep- 
tions, even when the accumulation of liquid is sufficient to remove 
the heart to the right of the sternum. The increase in frequency is 
rarely great while patients are tranquil. Exercise or the use of the 
voice in conversation furnishes the evidence of want of breath. Under 
these circumstances dyspnoea, with lividity of the prolabia, may be 
produced, which is rarely observed while patients are at rest. The 
pulse in the majority of cases is more or less accelerated, ranging 
from 80 to 120 per minute ; but I have observed it to be even below 
the normal average, viz., 64 per minute. Sweating frequently occurs 
at night, not uniformly preceded by a febrile paroxysm or exacer- 
bation. Chills or chilly sensations from time to time are apt to occur, 
even when the disease is simple, i. e. not complicated with tubercu- 
losis, and also when the liquid contained in the chest is not pu- 
rulent. The digestive functions may be more or less disordered, 
but in some instances the appetite is good, and the ingestion of food 
occasions no disturbance during the whole progress of the disease. 
Pallor of the countenance is marked in some cases, but in others the 
aspect is not notably morbid, although the chest be filled with liquid 
effusion. In a large proportion of cases, if the disease be uncompli- 
cated, the progress of the affection is not attended by great loss of 
weight or emaciation. The strength is sometimes preserved in an 
astonishing degree. I have known instances in which the disease was 
allowed to pursue its course without receiving any medical treatment, 
the patients prosecuting most of the time laborious occupations. The 
diagnosis in these cases was, of course, made retrospectively. It is 
not uncommon for cases to come under observation when the dis- 
ease has existed for several weeks or even months without any pre- 
vious application having been made for medical aid ; little or no in- 
convenience having been experienced except from want of breath in 
active exercise. Employments involving violent exertions, such as 
chopping and sawing wood, stone-cutting, the duties of a house-maid 



570 DISEASES OF THE KESPIRATORX ORGANS. 

of all work, and active participation in the rougli out-door sports of 
youth, have been continued in cases that have fallen under my notice 
when the chest was filled with liquid, which, under these circumstances, 
has progressively diminished by absorption.^ 

The symptoms of chronic pleuritis embracing so little that is dis- 
tinctive, not only is it confounded with other pulmonary diseases, 
especially phthisis, by those who do not avail themselves of physical 
exploration, but frequently even the existence of a pulmonary affection 
is not suspected. Latent intermittent fever, bilious fever, dyspepsia, 
general debility, disease of heart, and the ideal affection called "liver 
complaint," are the maladies under which patients have been supposed 
to labor in cases that have fallen under my observation. 

To determine the existence of the disease with the aid of physical 
signs is generally one of the easiest problems in diagnosis. I have, 
however, known the phenomena to be attributed to hepatization of 
lung by those who had given some attention to the exploration of the 
chest. Circumstances pertaining to the physical signs suffice for the 
discrimination between the presence of an abundant effusion and the 
solidification from pneumonitis. The points involved in this discrimi- 
nation have already been presented in connection with acute pleuritis, 
and need not be recapitulated. But in view of the previous history, 
when flatness is found to extend more or less over the chest in cases 
of chronic plem^itis, pneumonitis is almost excluded by the law of 
probabilities alone. Antecedent acute inflammation of the pulmonary 
parenchyma would be evidenced in the vast majority of instances, by 
rational symptoms having occurred which do not accompany the de- 
velopment of chronic pleuritis, viz., pain, rusty expectoration, febrile 
movement, and confinement to the bed for a certain period. But, 
irrespective of this point, the existence of chronic pneumonitis, either 
as a sequel of the acute form of the disease or as a primary affection, 
is exceedingly improbable. 

The affections which may give rise to phenomena closely analogous 
to those belonging to chronic plem'itis, are infiltrated cancer of 
the lungs and mediastinal tumor. These affections are much less 
frequent in their occurrence than chronic pleuritis, and the liability, 
therefore, to error, is in attributing their phenomena to the latter 
affection ; in other words, to suppose that chronic pleurisy exists, 

■I The rate of mortality from uncomplicated chronic pleurisy in my experience is about 
17 per cent. 



CHRONIC PLEURITIS. 571 

when they are present. The liability to this error is somewhat in- 
creased by the fact that in both these affections pleuritic effusion is 
apt to occur. Infiltrated cancer of the lung produces contraction of 
the affected side of the chest. Mediastinal tumor, on the other hand, 
may lead to dilatation. In the first instance, the disease may be 
mistaken for pleuritis advanced to the-^econd period, or the stage of 
absorption. In the second instance, pleuritis in the first period, or 
stage of liquid accumulation, may be supposed to exist. The points 
involved in the differential diagnosis from these affections have been 
already noticed in the preceding chapter, under the heads of Cancer 
of the Lungs, and Cancer in the Mediastinum. A brief reference to 
them will be all that is requisite in this place. 

A cancerous affection of the lungs or mediastinum (and it may co- 
exist in the two situations) is more uniformly accompanied by cough 
and expectoration than chronic pleuritis. The expectoration is more 
abundant, becoming purulent, and is frequently characteristic, re- 
sembling red or black currant jelly. Haemoptysis is an event of 
frequent occurrence. Pain is a more prominent and persisting symp- 
tom. 'The pulse, on the contrary, is less commonly accelerated until 
the affection is quite advanced. The contraction of the chest, pro- 
duced by the absorption of the liquid effusion in chronic pleuritis, is 
usually greater than in cases of infiltrated cancer. In the latter 
affection, the loss of strength, emaciation, and pallor, denote a graver 
malady than uncomplicated chronic pleuritis. 

Cancer in the mediastinum frequently extends more or less into 
both sides of the chest, giving rise, of course, to flatness on percus- 
sion and other physical phenomena, not limited to one side, as in 
cases of chronic pleuritis. Effacement of the intercostal depressions, 
and a sense of fluctuation, may be produced by the pressure of a 
tumor, but only in rare instances, while these effects are common 
when the side is dilated by the presence of liquid. The dilatation 
from a cancerous or other tumor is often partial or circumscribed, 
irregular, and extends from above downw^ard ; while in the stage of 
accumulation, in chronic pleuritis, it becomes general, extending from 
below upward, and the enlargement is more regular. Dyspnoea is a 
more constant and prominent symptom, in cases in which a tumor 
exists of sufiicient size to occasion a considerable dilatation of the 
chest. In both diseases, the heart and diaphragm, as well as the 
lung, are subject to displacement. But when this occurs from the 
pressure of a tumor, certain symptoms are frequently superadded to 



S12 IISZASZS ;i IHZ ?. Z5?IRAT0RT orgams. 

those incident to an equal amount of displacement from the accumu- 
lation of liquid; viz., oedema of the face, lividity, swelling of the 
Teins, dysphagia^ as well as marked djspnoea. These symptoms are 
due to pressure on the air-tubes, large yessels, nerres, and oesophagus ; 
and Hquid accumulation in the pleura, however large, never produces 
an amount of pressure on these parts, equal to that which results 
from ■?: l-:*rge mediastinal tumor. The symptoms, therefore, just 
iLf : , are distinctive of the latter. 

Et ^ ^ -: physical signs, in c:: : : :^> / :_ in the 

THi _:. z-^e bronchial respiration uIivl iiicivraSr . : : _ : - ^ ^nce, 

lion J, are often found over the parts of :lr ciif-:. vrliere 
:':- > — i L.- sound is dull or flat. These are eminently the signs 

in " i: ':5 cation. On the other hand, in chronic pleuritis, 
- n: : _n ::»ry murmur and abolition of vocal resonance, 

below the level of the Hquid, is the rule ; the reverse occurring in 
only exceptional instances. Absence of respiratory and vocal sound, 
with flatness on percussion, is a combination of signs eminently dis- 
tinctive of the presence of liquid. Yocal fremitus may be preserved 
or increased in cases of cancerous infiltration or tumor. It is uni- 
formly abolished below the level of the liquid, in chronic pleuritis. 
In the former afiections, we may expect often to find vesicular reso- 
nance on percussion, at or near the base of the chest, below the limit 
of dulness or flatness. In chronic pleuritis, in all save some very 
rare instances, we find flatness from the base of the chest extending 
more or less upward. 

The distinctive circumstances involved in the diiereatial diagn(^? 
of chronic pleuritis from cancer in the mediastinum are applicable, 
in a great measure, to the discrimination in cases of intra-thoracic 
tumor, arising from any other part exterior to tbe Iriz^p. 

BJETBOSPEcnYE DiAGifOsis CI cejm: iLEimins. 

Cases not infrequently are presented in practice in which it is 
important to determine, from an examination of the chest, whether 
chronic pleuritis have existed at some former period. A sense of weak- 
ness in the chest, and some deficiency of breath on active exercise, are 
apt to remain for a long time afrer recover v — :ii?.: is, after the liquid 
effusion is completely absorbed, and there are no other symptoms 
which denote any pulmonary affection. Instances of this description 
have come under my observation, in which patients had experienced 



CHRONIC PLEURITIS. 573 

the disease several years before, its character, perhaps, at the time, 
not having been determined. In other cases there are present symp- 
toms which may be due to some existing affection of the lungs, and 
in endeavoring to ascertain its nature, the permanent changes which 
have resulted from the pleuritis, must be taken into account. Chronic 
pleuritis may lead to certain consecutive affections. Dilatation of the 
bronchial tubes has been observed to follow. Emphysema may be 
a result. It has been supposed to increase the liability to pul- 
monary tuberculosis. Statistics show this opinion to be incorrect ;^ 
but phthisis, of course, supervenes in some instances, and it is not 
infrequently an important problem to solve, in individual cases, 
whether this be so or not ; a problem which, as has been seen already, 
is rendered more difficult by the changes consequent on the absorp- 
tion of a large pleuritic effusion. The retrospective diagnosis of 
chronic pleuritis, therefore, is a subject which appears to me deserv- 
ing of separate consideration. 

The diagnosis is made retrospectively by means of the remote or 
permanent effects of the disease. These are essentially the proximate 
effects, which do not entirely disappear for an indefinite period, or 
even during the remainder of life, and they have already been ad- 
verted to. They consist in contraction of the chest, alterations 
in the relations of different anatomical parts on the exterior of 
the thoracic parietes, displacement, in some instances, of intra- 
thoracic organs, and variations in percussion, respiratory and vocal 
sounds — in short, disturbance of the natural symmetry of the two 
sides of the chest, as respects the results furnished by the different 
methods of physical examination. This disturbance of symmetry, 
presenting characters which, collectively, are highly significant of 
the pre-existence of chronic pleuritis, justify a retrospective diagnosis. 
For what length of time after recovery is this diagnosis practicable ? 
This will, of course, depend on the persistency of the characters just 
referred to. The period doubtless varies in different cases. The 
changes immediately succeeding the disease gradually diminish, and 
examinations repeated at long intervals show progressive advance- 
ment toward restoration of the natural symmetry. Much will depend 
on the extent of the proximate effects. The age of the patient will 
also affect the final condition. In proportion to youth, other things 

* Vide " Practical Observations on Certain Diseases of the Chest, etc By Peyton 
Blakiston, M.D." Am. Ed. 1848. Also, " Clinical Report on Chronic Pleurisy," by 
author. 



574 DISEASES OF THE EESPIRATORY ORGANS. 

being equal, will be the ultimate approximation to tlie normal sym- 
metry. But it is probable that in many, if not most instances, cha- 
racters sufficient for a retrospective diagnosis remain during life. I 
have preserved notes of two examinations made ten years after re- 
covery, and in both the traces of the disease were strongly marked. 
The brief account which I shall give of the remote effects on which 
the retrospective diagnosis is to be based, will be derived from the 
recorded results of fifteen examinations of different patients, made at 
periods varying from ten months to ten years from the date of the 
attack. In all these cases recovery had taken place, and the patients 
(all of them adults), so far ^s could be judged from the symptoms 
and signs, were free from existing pulmonary disease.^ 

Of fourteen cases in which either the existence or non-existence of 
diminished width of the chest was noted, it had occurred in all save 
two, and in these two instances there was flattening of the summit. 
In one case, at the summit of the affected side, instead of depression, 
there was greater comparative fulness ; and this, coexisting with a 
clear, vesiculo-tympanitic percussion-resonance, and feebleness of the 
respiratory murmur, rendered it probable that emphysema had be- 
come developed in that situation. In the two instances in which 
diminished width was not apparent, the examinations were made in 
one ten months, and in the other three years from the date of the 
disease. The relative measurements of the semi-circumference of the 
two sides were noted in six cases. In these cases the contraction 
varied from half an inch to one and a half inches, always allowing 
for the right side half an inch as a normal disparity. The compara- 
tive contraction of the affected side after pleuritis is partly absolute 
and in part relative, the opposite side augmenting in size from the 
hypertrophy of lung resulting from the supplementary increase of 
the respiratory movements. The disparity between the two sides 
which immediately follows absorption, gradually becomes less, espe- 
cially if the patient be young. For example, in a case attended with 
large effusion, removing the heart to the right of the sternum (the 
left side being affected), the contraction after recovery was strongly 
marked. In the space of four years, the contracted side had ex- 
panded so as to leave but a slight apparent difference. A similar 
change, after the lapse of two years, I have noted in another case. 
In both instances the patients were young. 

^ Two cases are to be excepted from this remark, in one dilatation of the bronchial 
tubes, and in the other partial ernphvtema being supposed to exist. 



CHRONIC PLEURITIS. 575 

Of fourteen cases the shoulder was depressed in all but three. In 
one instance it was slightly elevated on the affected side. 

Of five cases in which the vertical position of the nipple was noted, 
it was lowered in four and raised in one. In one instance it was an 
inch lower than its fellow. 

Its distance from the median line was noted in three cases, and in 
all it was nearer, the difference varying from a quarter of an inch to 
an inch. 

The distance between the lower ribs was compared on the two sides 
in three cases, and in all it was diminished on the afiected side. In 
one instance the ribs approximated so as almost to overlap. In this 
case there existed a deep depression on the inferior anterior surface 
of the chest. In two instances the upper ribs were compared in this 
respect, and found to be divergent on the affected side. 

In nine cases the comparative width of the interscapular spaces 
was noted, and in eight it was lessened on the affected side. In one 
instance it was one-half less on that side than on the other. The 
difference was in no case less than one and a quarter inches. In 
the single excepted instance in which the width was greater on the 
affected side, this was evidently owing to the existence of spinal 
curvature, the convexity looking to the opposite side. Projection of 
the lower angle of the scapula existed in all the cases in which the 
facts with respect to this point were noted, viz., in four ; the same re- 
mark will apply to lowering of the scapula, which was noted in four 
cases. 

Of fourteen cases in which the results of a comparison of the 
breathing movements on the two sides were noted, in all save one 
they were more or less diminished on the affected side. This com- 
parative diminution was evidently in a measure due to an exaggerated 
expansibility on the opposite side. 

Dulness on percussion, as compared with the resonance on the side 
not affected, existed in every instance in which information relative 
to this point was noted, viz., in thirteen cases. 

Great clearness of the percussion-resonance was uniformly observed 
on the opposite side, and this contributed to render the contrast be- 
tween the two sides more striking. 

Eeebleness of the respiratory sound over the whole of the affected 
side existed in eleven of thirteen cases. This was rendered more 
marked by an unusual intensity of the vesicular murmur on the oppo- 
site side. In one of the two excepted eases, bronchial respiration on 
the affected side behind, below the scapula, existed, in conjunction 



576 DiszASzs or izz ei:5pibatoey organs. 

witli marked bronchoplioi^T. :Lc respiration being bronclio-TeEicnlar. 
and the vocal resonance comparatiTely feeble over the scapnla. This 
combination of signs rendered the existencfe of dilatation of the 
bronchial tubes probable. In the other case, bronchial respiration 
and bronchophony existed in the interscapnlar space on the affected 
side. The respiration was interrupted on the affected side, at the 
summit, in one instance. In five cases the respiratory sound pre- 
sented certain of the characters of the broncho-Tesicuiar respiration, 
consisting either in the diminished resicular quality, "with elevation of 
pitch of the inspiration, or a prolonged expiration. The absence of 
these characters in the other cases is not always stated. 

The results of a comparison as r^pects vocal resonance are given 
in ten instances. In six of these cases the resonance was greater on 
the affected side ; but of these sis cases, in three, the right side was 
the one affected. On the other hand, the four cases in which the 
Tocal r^onance was not greater on the affected side, included two in 
which the left side was the one affected. 

Of six cases in which the vocal fremitus on the two sid^ was 
compared, in four it was greater on the affected side, and in three of 
th^e four instances the left side was the one affected. 

The situation of the apex impulse of the heart was noted in seven 
cases. It was normal in three instances. In the remaining four in- 
stances the facts were as follows : in two cases an impulse was per- 
ceptible between the third and fourth, and also berween the fourth 
and fifth ribs. In one of these instances it was noted that the move- 
ments in these two situations were in alternation (" quasi undulatory"). 
In both the left side was the one affected. In one instance the im- 
pulse was on a line with the nipple, and one and a half inches below 
it. In the other case a diffosed pulsation was apparent over an area 
three inches in diameter, situated above the nipple. In the two last 
instances the left side was the one affected. 

Curvature of the spine was noted in four of seven cases. In three 
instances the curvature was lateral, and in one instance in an ante- 
rior direction, causing the patient to assume a stooping gait. 

The foregoing results are not given as embracing data sufficient 
for determining the numerical ratio in which the several changes 
respectively occur. This would be an interesting object of inquiry, 
and I regret that I have not availed myself of the opportunities that 
have been presented, to accumulate materials for an analysis with refe- 
rence to it. In the few cases analyzed, it wiU be observed that pains 
were taken to note facts respecting all the points in a small propor- 



CHRONIC PLEURITIS. 577 

tion only, the attention, in most instances, being limited to obvious 
contraction, a comparison of the expansibility, the percussion-sound, 
and the intensity of the respiratory murmur. The results, however, 
are adequate to show the group of characters by means of which the 
retrospective diagnosis is to be made, for many months or years after 
recovery from chronic pleurisy. This is the only purpose I have had 
in view, and these characters, recapitulated, are embraced in the 
summary which follows. 

SUMMARY OF CHARACTERS INVOLVED IN THE RETROSPECTIVE 
DIAGNOSIS OF CHRONIC PLEURISY. 

Diminished width of the chest, apparent on inspection in the great 
majority of cases. Depression or flattening at the summit of the 
affected side, almost invariably observed ; but occasionally enlarge- 
ment, which probably denotes abnormal dilatation of the cells, or 
emphysema. The reduction in size also shown by mensuration. 
The shoulder generally depressed ; but in some instances this is not 
apparent, and it may be even raised above the level of that on the 
opposite side. The nipple usually depressed, but not invariably, and 
nearer the median line. The lower ribs converging, sometimes 
almost overlapping ; the upper ribs diverging. The distance from 
the posterior margin of the scapula to the spinal column lessened, 
often in a notable degree ; an exception to this rule obtaining, in 
some instances, when lateral curvature of the spine takes place, the 
concavity looking toward the affected side. Projection of the lower 
portion of the scapula, occurring in a certain proportion of instances ; 
and, also, depression of the inferior angle below the level of that on 
the opposite side. The respiratory movements almost uniformly 
diminished in a degree more or less marked ; the expansibility on the 
opposite side being, at the same time, exaggerated. Comparative 
dulness on percussion ; the contrast rendered more striking by the 
great clearness of the percussion-resonance on the opposite side. A 
vesiculo-tympariitic resonance at the summit, conjoined with enlarge- 
ment, denoting the supervention of emphysema. Feebleness of 
respiratory sound over the entire side, with few exceptions ; and on 
the opposite side, an unusually intense vesicular murmur. A bron- 
chial respiration sometimes observed in the interscapular space, and 
in other parts of the side. In the latter, especially if associated 
with bronchophony, probably denoting dilatation of the bronchial 

37 



578 DISEASES OF THE RESPIRATORY ORGANS. 

tubes. The respiration, in a certain proportion of cases, broncho- 
vesicular. The vocal resonance sometimes greater, but not uniformly. 
The same remark applicable to vocal fremitus. Curvature of the 
spine in some cases, the inclination usually lateral, the concavity 
toward the affected side. The position of the heart frequently 
normal, but in some instances displacement of this organ ; it being 
found to the left of its natural position and elevated, if the pleuritis 
be seated in the left side.^ 

It will be borne in mind that this summary embraces characters 
observed in persons after complete recovery from chronic pleuritis, 
and presumed to be entirely free from any existing pulmonary dis- 
ease, excepting, in some instances, emphysema and dilatation of the 
bronchial tubes. 

Empyema. 

When the liquid contents of the pleura are purulent, the affection 
is generally called eni'pyema ; a better term, used by some writers, 
i^pyothorax. Empyema is, in fact, only a variety of pleuritis ; but in 
view of certain pathological peculiarities, there is a propriety in 
considering it as a distinct form of the disease. Inflammation, either 
acute or chronic, in this, as in other situations, evinces in some in- 
stances a peculiar tendency to the formation of pus. H^i^ tendency 
is independent of the intensity, nor does it depend on the duration 
of the inflammation or the amount of effused products. The symp- 
toms denoting a high grade of inflammatory action may be equally 
absent when the chest is filled with purulent matter, as in ordinary 
cases of chronic pleuritis ; and death may occur with an accumula- 
tion of pleuritic effusion of long standing when the chest contains 
only serum and lymph. Empyema, therefore, seems to be a species 
of pleuritic inflammation differing from ordinary pleuritis, ah initio^ in 
a tendency to the formation of pus. 

Clinically, however, it is by no means easy to distinguish empyema 
from ordinary chronic pleuritis, and, indeed, a positive discrimina- 
tion by means of the symptoms and signs is impracticable. The 
physical phenomena in both are equally those which are due to 
an accumulation of liquid. There are none which are distinctive of 
the character of the liquid. Bulging between the ribs, which has been 

^ The liability of the heart to be permanently drawn toward the right side after 
pleuritis aflecting that side, has been already adverted to. 



EMPYEMA. 579 

supposed to indicate the presence of pus rather than serous effusion, 
depends on the quantity of liquid, together with a condition of the 
intercostal spaces which renders them yielding to pressure, and is 
significant alike of both varieties. The occurrence of hectic parox- 
ysms, of more marked and persisting febrile movement, or greater 
gravity of the local and general symptoms, cannot be relied upon. 
I have known the fact of an enormous accumulation of liquid, which 
was found to be purulent, to be discovered accidentally only a few 
days before death. Cases of empyema, as well as of ordinary chronic 
pleuritis, are liable to be overlooked, patients being able to go about, 
and supposed to labor only under general debility, or some malady 
not seated in the chest. Such instances have fallen under my notice. 

Assuming it to be determined that the pleural sac is more or less 
filled with liquid, a point which, as has been seen, by means of phy- 
sical exploration, may be settled with promptness and certainty, it is 
highly desirable, with reference to the prognosis and the manage- 
ment, to decide, if possible, whether the liquid be purulent or not. 
A rational conclusion may be formed with considerable confidence 
if, the quantity of liquid being large, it remains stationary, and, more 
especially, if it continue to" increase, in spite of judicious therapeutical 
measures to promote its diminution by absorption. In the great 
majority of cases of ordinary chronic pleuritis these measures are, to 
a greater or* less extent, successful : the amount of fluid is reduced, 
although, after a time, its farther reduction may not be effected. A 
purulent fluid being with more difficulty absorbed, it is much more 
likely to remain undiminished or to increase. As regards the relative 
quantity of liquid at different periods, this can of course be ascer- 
tained with precision by repeated explorations. 

But although the physical signs and symptoms are not adequate to 
afford positive information as to the character of the liquid contained 
in the pleura, this point may be settled readily and demonstratively 
by a method involving little or no difficulty or danger. I refer to 
the use of the exploring canula. The cases reported within the past 
few years by Dr. Bowditch, of Boston, in which 2:)a7^acentesis thoracis 
was performed after the plan proposed by Dr. Morrill Wyman, of 
Cambridge, Mass.,^ show that the operation may be resorted to with 

' Vide Am. Jour, of Med. Sciences, April, 1852. The method referred to consists in 
using a small canula, which is attached by a flexible tube to a suction-pump, so con- 
structed that the fluid may be removed from the chest through the canula, and discharged 
from the pump through another aperture. 



580 DISEASES OF THE EESPIRATORT ORGAN'S. 

ease and safety, in order to determine the nature of the liquid con- 
tents of the chest. 

To discuss the merits of this operation, as of other therapeutical 
measures, does not fall -within the scope of this work. "With reference 
to its performance, the importance of being able, by means of physi- 
cal signs, to determine positively the presence of effusion, is sufS- 
ciently obvious. Heretofore the question as to the propriety of re- 
sorting to this operation involved the liability of mistaking ordinary 
pleuritis or empyema for other affections ; and the operation has 
frequently been performed -svhen there was no liquid within the pleural 
cavity. An instance of this kind has occurred within my own know- 
ledge. Uncertainty in diagnosis is no longer a valid reason either 
for omitting or delaying to puncture the chest. 

It is chiefly in cases of empyema that the contents of the pleural 
sac are discharged spontaneously, by means of ulceration and a fistu- 
lous communication, either directly through the thoracic parietes, or 
indirectly through some natural outlet. The evacuation may take 
place through the bronchial tubes, which occurs next in frequency to 
perforation of the walls of the chest. It has been known to take 
place into the alimentary canal. The sudden occurrence of a copi- 
ous purulent expectoration, when the chest is known to contain liquid, 
is evidence that ulceration has ensued, commencing from within the 
pleural sac ; but the phenomena arising from the presence of air and 
liquid in the cavity of the pleura are speedily superadded ; — the affec- 
tion, in short, becomes pneumo-hydrothorax. 

When perforation of the thoracic parietes occurs, the purulent 
fluid collecting beneath the integument forms a fluctuating tumor, 
evidently situated exterior to the bony wall of the chest. If the pre- 
existence of an accumulation of liquid has not been ascertained, this 
tumor may be regarded as simply an abscess, not communicating 
with the interior of the chest. I have known this mistake to be 
committed by those who were not accustomed to employ physical 
exploration. The coexistence of the physical signs of a large accu- 
mulation of liquid in the pleural sac, renders the connection of the 
subcutaneous collection with empyema altogether probable. But 
this connection may be established by compression of the tumor. 
If it be simply an abscess beneath the integument, it is irreducible 
by pressure ; but if the fluid be derived from the chest through a 
perforation, it may be made in a great measure to disappear, by 
forcing its contents into the thoracic cavity. Again, a tumor con- 



I 



EMPYEMA. 581 

taining a fluid which communicates freely with liquid in the chest, 
will be observed to rise and fall with the successive acts of inspira- 
tion and expiration. Moreover, an abscess developed exterior to the 
chest would involve, generally at least, acute inflammation, accom- 
panied by pain, swelling, heat, and redness, prior to fluctuation. 
These local phenomena do not precede the appearance of a fluctua- 
ting tumor, due to perforation in the course of empyema. If the 
tumor be opened, under the erroneous impression that it is nothing 
more than a subcutaneous abscess, the great abundance of the 
purulent discharge will be likely to lead to a discovery of the errorr 

A fluctuating tumor beneath the integument, due to perforation 
in empyema, is sometimes found to pulsate synchronously with the 
beating of the heart. This may, at first, excite a suspicion of aneu- 
rism. The tumor is too rapidly developed, its liquid contents are 
too superficially situated, and the fluctuation too marked and exten- 
sive, to be aneurismal. The positive signs of aneurism are wanting, 
viz., the bellows' murmur and thrill; and the physical signs of an 
abundant accumulation of liquid in the chest remove all doubt as to 
its character. 

A pulsation is occasionally observed more or less difl*used over the 
afi"ected side, in cases of empyema, in which the liquid is retained 
within the pleural sac. This gives rise to a variety of the disease 
which has been called pulsating empyema. An instance has fallen 
under my observation, in which the shock communicated to the walls 
of tho aflected side led the attending physician to suppose that the 
case was one of disease of the heart.^ Moderate hypertrophy of the 
left ventricle actually existed, as ascertained after death. The 
circumstances, in such instance, which authorize the exclusion of 
aneurism are the absence of its positive signs furnished by ausculta- 
tion and palpation, viz., the bellows' murmur and thrill, together 
with the absence of the symptoms due to the pressure of an intra- 
thoracic tumor on the vessels, nerves, oesophagus, and air-passages — 
symptoms not belonging to the clinical history of liquid accumula- 
tion in the pleura, however large. Taken in connection with these 
negative points, the physical signs of a large quantity of liquid in 
the chest establishes the diagnosis. 

^ Clin. Report on Chronic Pleuritis, p. 47. 



582 DISEASES OF THE RESPIRATORY ORGANS. 



Circumscribed Pleuritis, with Liquid Effusion. 

Circumscribed inflammation of the pleura, either without much 
liquid effusion, called dry pleuritis, or the effusion not confined within 
the limits over which the inflammation extends, occurs as a complica- 
tion of other pulmonary affections, and has already been noticed in 
connection with pneumonitis and pulmonary tuberculosis. But pleu- 
ritis may be partial or circumscribed, and accompanied by more or 
less effusion of liquid, which is not diffused, and does not gravitate to 
the bottom of the sac, but is retained by adhesion at the borders of 
the area of the inflammation. Under these circumstances, the fluid 
is, as it were, encysted, occupying between the pleural surfaces a 
circumscribed space, varying in size and in situation. In some 
instances there exist several distinct collections of liquid, consti- 
tuting, if the fluid be purulent, what has been denominated multi- 
locular empyema. The latter variety, as well as that in which the 
affection is unilocular , occurs in persons who have previously had 
general pleuritis, followed by general agglutination of the pleural 
surfaces, more or less extensive, leaving one or more spaces in which 
the surfaces did not adhere. Subsequent attacks of inflammation 
limited to the non-agglutinated portions of the membrane, constitute 
circumscribed pleuritis, accompanied by an effusion restricted within 
the boundaries of the space or spaces in which the surfaces are free. 

These local collections of liquid may occur in different situations. 
They may be seated between the diaphragm and the base of the 
lung, or at any point between the costal and pulmonary portions of 
the pleura, on the anterior, posterior, or lateral surfaces, and they 
have been known to take place between the lobes, the latter having 
become adherent at the margins of the interlobar fissure. Circum- 
scribed inflammation, in these different situations respectively, is 
distinguished as costo-pulmonary, diaphragmatic, and interlobar pleu- 
ritis. _ 

If acute inflammation be seated in the diaphragmatic pleura, cer- 
tain symptoms are pointed out as somewhat distinctive, viz., severity 
of pain, forward inclination of the body, cough remarkably paroxys- 
mal, predominance of the superior costal type of breathing, hiccough, 
nausea, and vomiting, jaundice if the right side be affected, and 
sometimes the risus sardonicus? It may be doubted if these symp- 

' Walshe, op. cit. 



\ 



PLEURITIS WITH LIQUID EFFUSION. 583 



toms possess much diagnostic value. They are, however, worthy of 
being borne in mind, the more because the existence of a circum- 
scribed collection of fluid between the diaphragm and the base of the 
lungs is detected by means of physical signs with much greater 
dijB5culty than in other situations. In fact, when an accumulation 
exists in this part of the chest, if small or moderate in amount, a 
positive diagnosis is hardly attainable. Even with the advantage 
of the occurrence of perforation of the lung and the discharge 
through the bronchial tubes of purulent matter, assuming that tuber- 
culosis and pulmonary abscess are excluded by the negative results 
of physical exploration, it may be difficult to determine whether the 
collection of pus has taken place above the diaphragm or in a subja- 
cent organ. A case which came under my observation several years 
ago, will serve to illustrate this difficulty. A patient entered a hos- 
pital with a copious expectoration, apparently of pure pus, which had 
existed for some time. Ten ounces were expectorated in the space 
of twenty-four hours. He was not much emaciated ; the pulse was 
72 ; the respirations 24 ; moderate diarrhoea existed, and it was 
reported that the dejections sometimes contained pus ; but the latter 
point was not satisfactorily ascertained. Physical exploration fur- 
nished the following results. Emaciation not sufficient to render the 
outline of the ribs visible. Clear percussion-resonance at the sum- 
mit of the chest on both sides. Flatness on the right side from the 
base to the fourth rib in front. Behind, in the interscapular space, 
resonance clear on both sides. Flatness below the inferior angle and 
over the lower part of the right scapula. Tenderness on pressure at 
the lower part of the right side, extending below the boundary of the 
chest. Respiration on the left side exaggerated ; on the right side, 
above the fourth rib feeble, but vesicular; below the fourth rib absence 
of respiratory murmur, and a distinct, but not loud friction-sound with 
both respiratory acts. Behind, on the right side, respiration feeble, 
bronchial, and accompanied by a fine mucous or sub-crepitant rale. 
Bronchophony at the angle of the scapula. 

After the death of this patient, it was ascertained that a pleuritic 
abscess, as it may be called, was situated at the lower part of the 
right side of the chest. CJircumscribed inflammation, the pleural 
surfaces being free, existed over a strip five or six inches in width, 
at the base of the chest, extending from the lower part of the ster- 
num quite around the right side. Above this strip the pleural sur- 
fices were agglutinated. The lower lobe of the right lung was soli- 
dified ; otherwise the pulmonary organs were free from disease. 



584 DISEASES OF THE RESPIRATORY ORGANS. 

The situation of the circumscribed empyema, in this case, accorded 
with the physical signs; yet, in view of all circumstances, there 
being no evidence of general chronic pleuritis or empyema having 
existed, and balancing probabilities, hepatic abscess, evacuating 
through the lungs, had been suspected. 

In the diagnosis of circumscribed collections of liquid situated 
between the costo-pulmonary pleural surfaces, elsewhere than at the 
base of the chest, physical signs are more available. Dulness or 
flatness on percussion will be found over a space corresponding to 
the area within which the liquid is confined. Effacement of the 
intercostal depressions and even bulging may be observed in this 
space. The vocal fremitus may be wanting. The respiratory sound 
may be feeble or absent, together with abolition of vocal resonance. 
Surrounding the collection, owing to the pleuritic adhesions and con- 
densation of lung, the respiratory sound will be more or less deve- 
loped and broncho-vesicular. The signs just mentioned will be espe- 
cially marked in cases in which the area of pleuritic surface occupied 
by the effusion, and the quantity of the latter, are not small; and the 
diagnosis is made with more positiveness if the situation of the col- 
lection be in the middle third of the chest, and if there are present 
the e^ddences of general pleuritis having existed at some former 
period. 

If circumscribed pleuritis exist with a fistulous opening through 
the thoracic wall, the probe becomes an important instrument in 
diagnosis. An interesting case of this description, of traumatic 
origin, was recently under my observation through the kindness of 
my friend and colleague, Professor Gross. The patient, three months 
before, had received a wound from a hatchet, penetrating the chest 
on the left side, between the first and second ribs, about three inches 
from the median line. Acute general pleuritis followed ; but he was 
now able to be up and about, presenting a healthy aspect, free from 
cough or difficulty of respiration, except after active exercise. The 
left side was considerably contracted. A small fistulous open- 
ing existed at the place where the wound was received, from which 
about a table-spoonful of puriform liquid escaped daily. To evacuate 
the fluid, which he was accustomed to do twice daily, he was obliged 
to lie upon the floor with his face downward, and the body inclined 
to the left. A probe introduced into the orifice showed the existence 
of a circumscribed cavity, the vertical length being about five inches, 
and the orifice near its upper extremity. On forced expiration, air 



PLEURITIS WITH LIQUID EEFUSION. 585 

was expelled through the aperture with an audible noise ; and the 
patient stated that sometimes when the orifice was first opened by 
detaching the incrusted lymph with which it became sealed, the 
passage of the air occasioned a loud report. 

To prevent the accumulation of liquid in the cavity, Professor 
Gross penetrated it with a trochar at its lower extremity, and esta- 
blished, by means of a tent, a fistulous orifice in this situation. This 
treatment speedily effected a cure, the cavity becoming obliterated in 
a few weeks. 

The existence of several, or multilocular, collections was presumed 
in a case which came under my observation five years since, of which 
the following is a brief account. The patient, a girl fourteen years 
of age, had been subject for several years to a loud, hard cough, 
with a small, transparent, frothy expectoration. Five weeks pre- 
vious to the date of my examination, she had suddenly expectorated 
a quantity of purulent matter. She continued to expectorate the 
same matter for a day or two, and it then ceased. Afterward, during 
the five weeks, she had several similar attacks. The general health 
was not much impaired. On examination of the chest, there was 
moderate dulness on percussion at the summit of the right side, with 
no distinct abnormal modification of the respiratory sound. Abso- 
lute flatness existed over the lower and most of the middle third on 
the right side, with absence of respiration in front and laterally. Be- 
hind, on the right side, the percussion-resonance was clear to the 
base. No rales, nor either bronchial or cavernous respiration. Ten- 
derness on percussion was observed over the right mammary region. 
Nine months afterward, this patient seemed quite well, but on slight 
examination flatness over the lower part of the chest on the right 
side still existed. She had at that time had no purulent expectora- 
tion for some time. 

Interlobar pleuritis with liquid accumulation presents difficulties 
in the way of diagnosis still greater than when the collections are 
situated between the costo-pleural surfaces. The pressure of the 
liquid here is not directly upon the thoracic parietes. Pulmonary 
substance, more or less compressed, intervenes between the liquid and 
the walls of the chest. The percussion-resonance will, therefore, be 
more or less dull, but not flat; and effacement of the intercostal 
depressions, or bulging, will not be likely to occur. The respiratory 
sound will be feeble and more or less broncho-vesicular, or even bron- 
chial, from the presence of condensed lung. Dr. Walshe mentions 



586 DISEASES OF THE RESPIRATOKY ORGANS. 

the fact of the accumulation being in the line of the interlobar fissure, 
as a point having a bearing on the diagnosis. 

Circumscribed pleuritis with liquid effusion is by no means of fre- 
quent occmTence. It is only now and then that cases occur to puzzle 
the diagnostician. 



Hydrothorax. 

Serous effusion within the pleura, not due to inflammation, consti- 
tutes the affection called hydrothorax. The effusion is purely serous, 
i. e. serum unmixed with inflammatory products. The affection is 
never primitive or idiopathic. It occurs always as an effect or com- 
plication of some other disease ; and in the great majority of cases it 
coexists with general dropsy incident to structural lesions of the heart 
or kidneys. 

The diagnosis claims but a few words. Its pathological connections 
constitute a diagnostic point. We look, as a matter of course, for 
more or less effusion into the chest in cases of cardiac or renal dropsy. 
The affection is always double. The causes act equally on both sides, 
their modus operandi being purely mechanical. For this reason it 
is impossible that the quantity of effusion should ever be sufficient 
completely to fill the chest. A near approach to this amount of ac- 
cumulation in both sides would be incompatible with life. And in 
consequence of the affection being double, a moderate amount of effu- 
sion is productive of far greater disturbance of the respiratory func- 
tion, as induced by accelerated breathing, dyspnoea, lividity, etc., 
than belongs to cases of chronic pleuritis in which the whole of one 
side is filled with liquid. Moreover, the pathological conditions asso- 
ciated with hydrothorax, such as ascites, hydro-pericardium, organic 
disease of heart, general debility, render the system less able to bear 
up under a diminution of the respiratory function, than in the majority 
of cases of chronic pleuritis. 

Except in degree, the positive symptoms offer nothing distinctive 
of hydrothorax. Negatively it is distinguished from pleuritis by the 
absence of the symptomatic pjienomena due to inflammation, viz., lan- 
cinating pain, tenderness on pressure, and cough. These phenomena, 
present to a greater or less extent in many cases of pleuritis, are 
wanting in hydrothorax, or, at least, do not constitute a part of its 
semeiological history. 



H Y D E T H R A X. 587 

The physical signs representing a certain quantity of liquid in the 
pleural sac, displacing the lung, perhaps occasioning some enlarge- 
ment of the inferior portion of the chest, and depressing the dia- 
phragm, are essentially the same in hydrothorax as in pleuritis. It 
is unnecessary to recapitulate them in this connection. There are, 
however, certain distinctive points pertaining to the physical pheno- 
mena, which possess diagnostic significance. The visible changes in 
size, form, and expansibility, resulting from a very large accumulation 
of liquid, which are observed in cases of chronic pleuritis, are of 
course never exhibited in cases of hydrothorax, because a similar 
amount of accumulation in both sides is incompatible with life. This 
has less clinical value as a distinctive feature than those which remain 
to be mentioned. In hydrothorax, friction-sounds do not occur. The 
condition for their production, viz., roughening of the pleural sur- 
faces by a deposit of lymph, is incident to inflammation, and does 
not obtain in a purely dropsical aifection. This is a negative point. 
A positive point is, that in cases of non-inflammatory serous efi'usion, 
the liquid, as a rule, if not invariably, can be made to change its 
level by varying the position of the patient ; the quantity of liquid 
never becoming very large, and the pleural surfaces remaining free, 
this test of the existence of effusion is always or generally available, 
while in pleuritis it is employed successfully in a certain proportion 
of cases only. 

The points thus briefly adverted to, pertaining to the symptoms 
and signs, taken in connection with the existence of efi'usion on both 
sides, and the fact that the aff'ection occurs only as a complication of 
other diseases, which give rise at the same time to general dropsy, 
render the diagnosis of hydrothorax easy and positive. 



Pneumothorax — Pneumo-Hydrothorax. 

An abnormal condition, consisting in the accumulation of air or 
gas within the pleural sac, unaccompanied by liquid efi'usion, is de- 
nominated pneumothorax. Thus defined, the affection may be said 
to be almost infinitely rare. The secretion or exhalation of air or 
gas from the pleural surfaces, must be regarded as extremely 
problematical. Pleural rupture over the dilated cells in vesicular em- 
physema, or of the blebs which are occasionally formed in the inter- 
lobular variety of this disease, is an accident which has been known 



588 DISEASES OF THE RESPIRATORY ORGANS. 

to occur in a few instances, giving rise to an accumulation of air in 
the pleura, unaccompanied, for a time, at least, by any morbid pro- 
duct ; but, under these circumstances, inflammation is likely soon to 
supervene, and liquid effusion follows. 

Whenever air or gas gains access within the pleural cavity, by 
other modes, the accumulation of liquid either precedes or speedily 
ensues, and the coexistence of air or gas and liquid, let the character 
of the latter be what it may, gives rise to the affection called pneumo- 
hydrothorax. From what has been said, it follows that, although 
pneumothorax may exist as an affection distinct from pneumo-hydro- 
thorax, the latter, in a clinical point of view, is chiefly important. 
In relation to diagnosis, it will sufiice to consider both affections 
under the head of pneumo-hydrothorax, making incidental mention 
of the circumstances which characterize the presence of air without 
liquid — in other words, pneumothorax. It is to be remarked that our 
knowledge of this, as of several pulmonary affections, is to be dated 
from the researches of the illustrious discoverer of auscultation. 

Pneumo-hydrothorax is always either of traumatic origin, or an 
effect of some antecedent morbid condition. It is never a primitive 
affection. And with reference to its discrimination, it is important 
to bear in mind the various modes in which it originates. Moreover, 
circumstances pertaining to its different pathological connections, 
affect materially both the symptoms and signs, more especially the 
latter, by which the diagnosis is established. 

In by far the larger proportion of cases it occurs as an accidental 
complication of pulmonary tuberculosis, being produced by perfora- 
tion of the lung resulting from rupture of the pleura over a cavity 
or a collection of softened tubercle. The rupture generally takes 
place during an act of coughing. Pneumothorax, then, becomes 
suddenly developed, and- is speedily followed by acute pleuritis, with 
liquid accumulation. The size of the perforation, the persistency of 
a fistulous opening, and the freedom of communication established 
between the pleural cavity and the bronchial tubes are circumstances 
having important bearings on the development of certain physical 
signs. Statistics show that this accident is much more liable to occur 
on the left than on the right side. The situation at which it is 
oftenest found to take place, may also be borne in mind with refe- 
rence to physical exploration. 

According to Walshe, it is on the postero-lateral surface between 



PNEUMOTHOKAX. 589 

the third and sixth ribs.^ Its occurrence in the progress of tubercu- 
losis is extremely rare. Several instances, however, have fallen 
under my observation. 

It is liable to occur in connection with circumscribed gangrene of 
the lung, the pleura giving way over the eschar, inducing, in like 
manner, perforation and pleuritis. This is a rare result of a rare 
form of disease. I have met with two instances. 

Perforation of the lung takes place still more rarely in connection 
with pulmonary apoplexy, tuberculous affection of bronchial glands, 
opening into the bronchial tubes and pleura, abscess, cancer, and 
hydatids. And it may be produced by an ulcerative process, taking 
its point of departure from the pleura, and extending to the bronchial 
tubes, in cases of chronic pleuritis and empyema. 

Perforation of the thoracic parietes may lead to the admission and 
accumulation of air within the pleural cavity. This takes place in 
certain cases of empyema. Abscesses situated in the walls of the 
chest may result in an external communication with the pleural cavity. 
Thus produced, cases of pneumo-hydrothorax are distinguished from 
those involving perforation of the lung, and communication with the 
bronchial tubes, by the absence of certain physical phenomena which 
involve the latter anatomical conditions in their production. 

Penetrating wounds of the chest, on the one hand, and, on the other 
hand, injuries of the lung from the fractured extremities of ribs, or 
contusion, are the modes by Vy^hich the affection is produced trau- 
matically. 

Instances have occurred of a fistulous communication between the 
alimentary canal (oesophagus and stomach) and the pleural sac, through 
which the gases from the former escape into the latter situation. 

Finally, in some very rare instances, chemical decomposition of 
liquid contained in the pleural sac takes place sufficiently to occasion 
development of gas, without perforation either of the lung, thoracic 
parietes, stomach, or oesophagus. In such cases, the phenomena 
which involve the admission of air from the bronchial tubes into the 
pleural cavity are of course wanting. 

In this category may be placed the transient production of gas, in 
some mode not easily accounted for, in connection with pneumonitis, 
of which an instance was reported by Dr. Graves, and another by 

' This is quoted as more correct than the statement made by some writers, that it is 
most liable to occur near the apex of the lung. The pleural adhesions so uniformly 
occurring at the summit render it less liable to occur in that situation. 



590 DISEASES OF THE RESPIRATORY ORGANS. 

Yalleix. These cases are so remarkable ^hat if they rested on the 
testimony of less competent observers, the accuracy of their observa- 
tion might well be questioned. 

Rupture of the lung in connection with emphysema, of which a few 
cases are on record, has already been referred to. 

The physical conditions incidental to pneumo-hydrothorax pro- 
duced in the various modes just mentioned, which are represented by 
physical signs, are the following. The presence of air or gas and 
liquid, in greater or less abundance, and in both varied and varying 
relative proportions. Perforation of the thoracic parietes, in some 
cases giving rise to fluctuations as respects the quantity, absolute and 
relative, of air and liquid. Communication with the bronchial tubes, 
in other cases, by which air enters more or less freely into the pleural 
cavity in respiration. To these conditions are to be added, those 
proper to the different antecedent diseases of the lung or pleura of 
which the pneumo-hydrothorax is a complication. 

Physical Signs. — The physical signs in pneumo-hydrothorax are 
highly distinctive. 

Over a space commensurate with that occupied by air or gas, the 
chest yields on percussion a marked degree of sonorousness, which is 
purely tympanitic in quality, and high in pitch, approaching fre- 
quently, in intensity as well as character, the sound in abdominal 
tympanitis. This clear hollow resonance is always found at or near 
the summit of the chest, extending downward a greater or less dis- 
tance, unless the lung be attached at its upper portion, so as to pre- 
vent its compression and the ascent of the gaseous fluid. The presence 
of the condensed lung, situated usually at the superior and posterior 
portion of the chest, may give rise to dulness in that situation. If 
air or gas be present without liquid efi'usion, the tympanitic sonor- 
ousness may be diffused over the greater part of the affected side. 
But as more or less liquid is almost invariably present, the sonorous- 
ness extends to a certain point, and below this point there is flatness 
on percussion. The spaces, relatively, which are occupied by the 
tympanitic resonance and the flatness due to liquid effusion, will be 
likely to vary at different times, especially if there exist a free com- 
munication either with the bronchial tubes, or, externally, by an out- 
let through the thoracic parietes. The escape of fluid by expectora- 
tion, or by external discharge, will of course affect the quantity 
retained within the chest, and thus occasion fluctuation in its amount. 



PNEUMOTHORAX. 591 

The introduction of air, also, is liable to variations, from obvious 
causes, as well as the production of gas by chemical changes. Ac- 
cording to Skoda, the boundary line at which the tympanitic sound 
ceases and flatness begins, does not mark with accuracy the level of 
the liquid, the former being propagated for a certain distance below 
this level. Skoda, indeed, states that we may reckon the quantity 
of liquid present as about double that indicated by percussion. 

Another fact has been pointed out especially by the author just 
named. It is, that when the accumulation of air or gas is large, 
owing to the tension of the thoracic wall the sonorousness is dimi- 
nished, and the sound may even become dull, the tympanitic quality 
being of course preserved. 

The tympanitic sound in some instances has a ringing, metallic 
tone, resembling that produced by percussion over the stomach, and 
which may be imitated by striking either the back of the hand when the 
palmar surface is applied firmly over the ear, or after the illustration 
given by Dr. Williams, a caoutchouc bottle held to the ear. This 
modification is sometimes discovered by practising auscultation and 
percussion simultaneously, when it is not rendered apparent by the 
latter alone. 

The line of demarcation between tympanitic sonorousness and flat- 
ness varies with the position of the patient, owing to variation of the 
level of the liquid. This test of the presence of liquid is more uni- 
formly available in pneumo-hydrothorax than in simple pleuritis. It 
is rarely the case that it is not available in the former afi*ection. 

Over the portion of the chest in which tympanitic sonorousness 
exists, the thoracic parietes are found to be highly elastic. On the 
other hand, below the level of the liquid eff'usion, there is deficiency 
of elasticity, and a marked sense of resistance felt on percussion or 
pressure. 

The diagnostic evidence aff"orded by percussion alone, is quite con- 
clusive in cases of pneumo-hydrothorax. The tympanitic resonance 
occasionally observed in connection with other morbid conditions 
can hardly lead to the error of confounding them with this afi*ection. 
A marked tympanitic sonorousness on the left side is sometimes due 
to the presence of gas in the stomach. The character of the gastric 
sound is distinctive ; but, aside from this, it is most marked at the 
lower portion of the chest, gradually diminishing as percussion is 
made toward the summit. Precisely the reverse obtains in pneumo- 
hydrothorax ; the sonorousness exists above, and the percussion-sound 
is rendered flat below by the presence of liquid. 



592 DISEASES OF THE RESPIRATORY ORGANS. 

The tympanitic sonorousness which is found in a certain propor- 
tion of cases of simple pleuritis over the compressed lung, above the 
level of the liquid, is never so strongly marked as in most cases of 
pneumo-hydrothorax. If the quantity of liquid be moderate, the 
sound is not purely tympanitic, but vesiculo-tympanitic. The relative 
situations of sonorousness and flatness are not altered to the same 
extent by changes of posture. The walls of the chest are not so 
elastic. However, auscultation shows, in the one case, the lung to be 
in contact with, and in the other case to be removed from, the walls 
of the chest above the liquid. 

The same remarks are applicable to the tympanitic resonance 
sometimes observed over lung solidified by inflammatory exudation. 
In the latter case, the bronchial respiration and bronchophony will 
be discovered by auscultation to be associated with the tympanitic 
sonorousness, and this combination, as will be seen presently, is proof 
not less against pneumo-hydrothorax than for the existence of pulmo- 
nary solidification. 

The exaggerated resonance in emphysema is not purely tympanitic, 
but vesiculo-tympanitic, and in this afi"ection the evidence of liquid 
in the chest is wanting. 

On auscultation, the respiratory sound, as a rule, is feeble, distant, 
and frequently suppressed over the space occupied by the gaseous 
accumulation, except a free communication exists between the pleural 
cavity and the bronchial tubes. When the latter condition obtains, 
the cavernous and amphoric respiration may be discovered. It is in 
cases of pneumo-hydrothorax especially, that the amphoric modifica- 
tion of the cavernous respiration is most marked. These respiratory 
sounds are not constantly present, even when the anatomical condi-* 
tion just mentioned, which is necessary for their production, exists. 
The perforation may at times be situated below the level of the 
liquid or the orifice, or the tubes leading thereto, are liable to become 
obstructed; either of these circumstances will prevent their develop- 
ment. The opening into the pleural cavity may be too small for their 
production. Other things being equal, their intensity will be pro- 
portionate to the size of the fistula, and the calibre of the bronchial 
tubes to which it leads. Skoda, explaining these signs by the 
theory of consonance, contends that communication is not necessary ; 
a thin stratum of tissue not preventing the production of the sounds. 
He is peculiar in entertaining the belief that the communication 
very rarely becomes persistent, the opening almost invariably being 



PNEUMOTHORAX. 593 

closed, partly by the compression of the lung, and partly by the 
effusion. 

The cavernous and amphoric sounds when present are not diffused 
equally over all the space occupied by air, but are either limited to 
a circumscribed area, or heard at a certain point with an intensity 
which gradually diminishes as the ear is removed from it. Their 
maximum of intensity is, of course, over the site of the perforation ; 
and they are therefore to be sought for in cases of tuberculosis where 
rupture is most apt to occur, viz., postero-laterally, between the third 
and sixth ribs. 

The respiratory sound is suppressed over the space occupied by 
liquid effusion. This space will extend from the base of the chest 
upward to a distance proportionate to the quantity of liquid. At the 
summit, especially behind, the bronchial respiration may be discovere(^ 
over the lung, which is not only condensed by pressure, but in addi- 
tion, generally solidified by tuberculous deposit. It is, however, 
rarely, if ever, loudly developed. According to Stokes, the existence 
of tuberculous cavities in the compressed lung may sometimes be 
ascertained by their physical signs. On the healthy side, the respi- 
ratory sound is exaggerated. 

The vocal phenomena vary not only in different cases, but in dif- 
ferent parts of the chest in the same case. Absent below the level 
of the liquid effusion, the resonance may be wanting, feeble, or more 
or less marked, over the space occupied by air or gas, with an 
amphoric intonation, under the circumstances which give rise to 
amphoric respiration. At the summit, over the compressed lung, we 
may expect to find, more or less frequently, marked resonance ; per- 
haps bronchophony, and possibly pectoriloquy. 

An adventitious sound incident to the respiration, voice, and cough, 
is almost pathognomonic of pneumo-hydrothorax. This is metallic 
tinkling. It is a pretty constant sign, at least in cases involving 
perforation of lung. Exclusive of this affection, it is never met with, 
except, very rarely, in large tuberculous excavations. A sound 
somewhat analogous is sometimes produced within the stomach. 
The latter is occasional, and is readily distinguished by the fact that 
it occurs irrespective of the respiration, voice, or cough. For an 
account of the characters belonging to this sign and the circum- 
stances (so far as known) connected with its production, the reader is 
referred to Part I.^ It is found generally over the middle third of 

* Vide page 282, et seq. 
38 



594 DISEASES OF THE RESPIRATORY ORGANS. 

the chest ; sometimes limited to the summit, and occasionally diffused 
over the greater part of the affected side. It has been known to 
accompany the act of deglutition, as well as the acts of breathing, 
speaking, and coughing. 

Inspection and mensuration furnish signs of importance. The 
affected side is permanently expanded, and its movements are accord- 
ingly limited. Frequently the accumulation of air and liquid leads 
to great dilatation and complete immobility, even with forced breath- 
ing. The intercostal spaces are widened and pushed outward, some- 
times beyond the level of the ribs ; the diaphragm is depressed, the 
mediastinum displaced, and the heart dislocated, being transferred, 
in some instances, to the right of the sternum — ^in short, the same 
appearances are presented as in cases of chronic pleuritis or emphy- 
sema. The signs furnished by inspection and mensuration alone 
would not enable the observer to distinguish between pneumo-hydro- 
thorax and chronic pleuritis or empyema. Percussion and ausculta- 
tion, however, at once supply differential characters. In chronic 
pleuritis and empyema with dilatation, the affected side is flat on 
percussion, with absence of respiratory sound in the great majority 
of instances, except over a small space at the summit. The strongly 
marked tympanitic sonorousness, extending over more or less of the 
affected side, cavernous, or amphoric respiration, and metallic tinkling, 
are wanting. 

Dilatation does not uniformly occur in pneumo-hydrothorax. 
Liquid and air or gas may exist in the pleural sac, compressing the 
lung, without manifest enlargement. Cases, however, in w^hich mor- 
bid changes in size and motion are not available in the diagnosis are 
exceptional. 

Palpation furnishes signs which belong alike to chronic pleuritis 
and empyema, viz., diminution or abolition of vocal fremitus and 
fluctuation. 

Finally, it is in this affection that succussion is available as a 
method of exploration. When air and liquid are contained in the 
pleural cavity, moving the trunk of the person to and fro, with the 
ear applied to the chest, produces a splashing noise, resembling that 
caused by shaking a bottle partly filled with water. This " Hippo- 
cratic succussion-sound," as it is frequently called, from the fact 
that it arrested the attention of the ancient father of medicine, is 
almost pathognomonic of pneumo-hydrothorax. The conditions under 
which it is presented, exclusive of this affection, occur only in 



PNEUMOTHORAX. 595 

pulmonary tuberculosis ; and in the latter disease their occurrence 
is extremely rare. A very large excavation, partially filled with 
liquid, combines the circumstances necessary for its production. In 
this connection, however, the associated signs and symptons, in con- 
junction with the history, are so distinctive of tuberculous disease, 
that the presence of the sign, should it happen to be discovered, can 
hardly prove a source of any perplexity as to the diagnosis. For a 
farther account of this sign, as incidental to the aifection under con- 
sideration, the reader is referred to the chapter in Part I, which 
treats of succussion.^ 

Diagnosis. — The symptoms of pneumo-hydrothorax, taken in con- 
nection with collateral circumstances, frequently are quite significant. 
In a very large majority of cases, the afi'ection occurs in the course 
of pulmonary tuberculosis, and results from perforation of the lung. 
This accident, generally taking place during an act of coughing, is 
signalized by sudden acute pain in the chest, speedily followed by 
great dyspnoea, hurried respiration, frequency of the^ pulse, prostra- 
tion, lividity, perspiration, diminished or suppressed expectoration, 
occasionally loss of voice, and an expression of great anxiety. When 
a case of phthisis ofi'ers this group of symptoms, manifested abruptly, 
perforation should be strongly suspected. At first, and for a brief 
period, the affection may be simply pneumothorax, but as acute 
pleuritis is generally quickly developed, with more or less liquid 
eifusion, the disease soon eventuates in pneumo-hydrothorax. If, 
however, the physician rely exclusively on the symptoms, he will be 
likely to fall into errors of diagnosis ; for the development of simple 
pleuritis may give rise to a group of phenomena, not unlike that 
just mentioned, and perhaps accompanied by a feeling, on the 
part of the patient, that something has given way in the chest ; so 
that, as remarked by Dr. Stokes, the thorax is sometimes explored 
with a strong expectation of finding the evidence of perforation, when 
the result is negative. And, on the other hand, perforation is not 
always attended, in a marked degree, by the symptoms which have 
been enumerated. In some instances it is not immediately followed 
by notable disturbance, either of the respiratory function or of the 
system at large. In these cases, either the perforation is so small 
that the air and morbid products escape slowly into the pleural sac, 
inflammation becoming gradually developed ; or extensive pleuritic 

' Vide chap, vii, page 330. 



596 DISEASES OF THE EESPIEATORY ORGANS. 

adhesions offer a meclianical obstacle to the accumulation of air and 
liquid. Even when intense dyspnoea, etc., immediately follow the 
occurrence of rupture, generally, after a time, the severity of the 
distress is considerably diminished. The functions of respiration and 
the circulation become adjusted to the morbid condition, and although 
afterward the accumulation of air may be greater than at first, and 
liquid effusion be added, the patient is perhaps comparatively com- 
fortable. In the majority of cases, whether occurring as a complica- 
tion of phthisis or of other affections, it runs rapidly on to a fatal 
issue. But there are exceptions to this rule. Although not probable, 
recovery is possible ; and patients have been known to live for years, 
preserviQg sufficient health and strength to take active exercise, and 
even to pursue laborious occupations. An instance has fallen under 
my own observation, in which the patient, a female, was able to ride 
and walk without difficulty for several months, there being habitually 
no embarrassment of the respiration. 

Occurring from perforation of the lung, in phthisis, gangrene, 
empyema, or other pulmonary affections which have been mentioned, 
as well as from traumatic causes : from perforation of the chest by 
ulceration, abscess, or wounds ; from ulcerative communication with 
the stomach or oesophagus, and from chemical decomposition of 
liquid LQ the pleural cavity, the signs are so distinctive and readily 
ascertained, that a positive diagnosis is rarely attended with any 
real difficulty, assuming the practitioner to be acquainted with the 
characteristics derived from the combined physical phenomena. The 
more important of the points involved in the discrimination from 
other affections have been noticed already, incidentally, in treating 
of the physical signs which belong to the affection. It seems, there- 
fore, unnecessary to make the differential diagnosis the subject of 
formal consideration. 



STnOIAfiT OF THE PHYSICAL SIGNS BELONGING TO PNEUMO-HYDRO- 

THORAX. 

Tympanitic sonorousness, usually intense, at the upper part of the 
chest, except in some instances, in which the ascent of air or gas is 
prevented by pleuritic adhesions ; the tympanitic sonorousness ex- 
tending for a greater or less distance downward, and if the accumu- 
lation be sufficient to produce lateral displacement of the medias- 
tinum, being sometimes apparent beyond the sternum on the opposite 



PLEURALGIA. bVl 

side. The percussion-sound sometimes presenting a metallic ringing 
tone. Flatness at the base of the chest extending upward in propor- 
tion to the quantity of liquid effusion. Marked elasticity of the thoracic 
parietes accompanying the tympanitic resonance, and an abnormal 
sense of resistance below the level of the liquid. Change of level of 
the liquid with different positions of the trunk. 

The respiratory sound feeble, distant, and often suppressed, if free 
communication between the cavity of the pleura and the bronchial 
tubes, does not exist. With such a communication, the cavernous 
and amphoric respiration frequently discovered. Possibly, in some 
instances, these signs are produced when a perforation which has 
taken place becomes closed by a thin stratum of false membrane. 
The cavernous and amphoric respiration oftenest heard, or the inten- 
sity greatest, between the third and sixth ribs, on the postero-lateral 
surface of the chest. Suppression of respiratory sound below the 
line of flatness, denoting the level of the liquid. Bronchial respira- 
tion, bronchophony, and possibly cavernous respiration and pecto- 
riloquy, over the compressed lung at the summit of the chest. 
Exaggerated or supplementary respiration on the healthy side. Yocal 
resonance, over the space yielding tympanitic sonorousness on percus- 
sion, either wanting, or feeble, with an amphoric intonation in some 
cases in which the respiration is amphoric. Over the space yielding 
a flat percussion-sound, absence of vocal resonance. 

Metallic tinkling frequently discovered, especially when the affec- 
tion coexists with perforation of lung, and if produced within the 
pleura, pathognomonic. 

Enlargement of the affected side, and diminished motion. Fre- 
quently great dilatation, involving effacement of intercostal depres- 
sion or bulging, depression of diaphragm, displacement of medias- 
tinum, and dislocation of the heart, and, under these circumstances, 
almost complete immobility even with forced breathing. 

Diminution or abolition of vocal fremitus, and in some cases fluc- 
tuation, ascertained by palpation. 

Hippocratic succussion-sound, or splashing. 



Pleuralgia. 

Under this head I shall refer not alone to neuralgia affecting the 
intercostal nerves, to which, perhaps, the term pleuralgia^ in a rigor- 



598: DISH^-I 7 rZZ ESSPIEArOET OE'lATS- 

anH aense, aKcraid be restricte<L hut to an jrffectron resemiling Aen- 
matiHiiL af ths nmscnlar or fibrons stmctores of tfce thoracic parietes, 
to wMcii the term ^lenrodynia is nsnaEj applied. A truly rfLemnatic 
affieetkuL is conrparatrTely- raare^ I sIiaE also alliidfi to tte nearaJgic 
afectioii called angina pectoris. WitKoiit contendnig for tiie noso- 
logical propriety of this arnmgenieiit, it is adopted for tlie sake of 
cflnreaiieiLceB, tie dragiostic poinia by wMcK tiese are (fiscrrnnnated 
from otter affections applying to aH of tRem alike. 30 far as con- 
cerns pkysical exploration. Tlie cfiaracters distingnishing tkem from 
eacL other wiH be noticed rncidentallT. 

Tbe local symptDma cliaracterizing intercostal neuralgia and 
plemrodynia are. in some respects. Yery analogons to those wbicb. 
belong to acnte plenritis. The differential diagnosis fr^jm. other affec- 
tiona relates almost exclnsirely to their discrrmf nation from the latter 
disease. And it will snffice to point ont the 'iistinctive characters 
involved in this discrimination. 

Pain is the prominent feature in both the neuralgic and rhemnatic 
affection. In its character and sitnarion. the pain may simnhitB 
clos^y that which is <hie to acnte inflammation of the pleura. Yary- 
ing in degree in (Efferent cases, it may be considerable or intense^ 
even exceeding the pain usually experienced in acute pleuritis. It 
is fre^^nently lancinating in character, and may be felt especially in 
inspiration. Acta of coupling or sneezing occasion sometimes exsTt- 
ciating suffering. It is generally referred to the lower portion of the 
chest, in front and lateraRv. — ^the seat of pain in manv cases of acnte 
pleuritis. B: is accompanied by tenderness on percusaion or pressure. 
Gnided solely by the rational or vital phenomena, it is sufficiently 
easy to confound intercostal neuralgia or pleurodynia with acnte 
plenritis ; and this sroTy in fect^ is not infrequently committed. More- 
over, in both affections, the physical phenomena which belong to the 
first stage of acnte plenritis may be eqnaHy present. The move- 
ments of the affected side are restrained : a disparity in this respect, 
and even a slight difference in width, may be apparent. The respi- 
ratory murmur is feeble and intemipted. Percussion may possibly 
elicit, comparatively, slight dulness. How. then, is the discrimina- 
tion to be made ? It involves attention both to symptoms and signs. 
together with the circumstances under which the affection is pre- 
seited; and. with proper care and knowledge, a positive diagnosis 
cannot always be at once established. 

Intearcofital neural^a, except as an occasional coincidence. _: " " 



PLEURALGIA. e599 

tended hj febrile movement, which is wanting also in the great ma- 
jority of the cases of pleurodynia. On the other hand, acute inflam- 
mation of the pleura gives rise to well-marked and more or less intense 
symptomatic fever. This is an important point of distinction. The 
absence of febrile movement is evidence against acute pleuritis, if we 
observe the disease at its commencement, or shortly after the attack. 
But the presence of febrile movement is not to the same extent 
evidence against intercostal neuralgia and pleurodynia, because it 
may accidentally coexist with these aifections. 

The extreme severity of the pain, and the exquisite sensitiveness of 
the side to the touch, in some cases, militate strongly against the idea 
of acute inflammation, provided symptomatic fever be absent. In 
neuralgia affecting the walls of the chest, the tenderness is more 
superficially situated ; the contact of the hand or slight pressure is 
not so well borne as in cases of acute inflammation, while firm steady 
pressure made with the open palm occasions a disproportionally less 
amount of suff'ering. Movements of the trunk and upper extremities 
produce distress in a severe attack of neuralgia frequently greater 
than in acute pleuritis, the respiratory movements being more espe- 
cially the cause of pain in the latter. The pain at the same time in 
neuralgia is more independent of respiration and the motions of the 
body. It is less uniform, marked remissions and sometimes distinct 
intermissions occasionally occurring. When this is the case it is 
quite distinctive. It may be sometimes promptly and efl"ectually 
relieved by a full opiate ; while the pain from acute inflammation may 
in this way be perhaps mitigated but not controlled. Cough is a 
more constant and prominent symptom in acute pleuritis. It is often 
wanting in intercostal neuralgia and pleurodynia. 

Both neuralgia and rheumatism, when seated in the thoracic walls, 
may be associated with similar aff'ections manifested at the same time 
in other parts of the body. This is ground for a presumption as to 
the character of the chest-aff'ection. In herpes zoster the acute 
pains in the chest may be presumed to be neuralgic, because severe 
thoracic pains are well known to accompany this affection without 
involving inflammation. The pathological association thus in this 
case becomes diagnostic. 

MM. Bassereau and Yalleix have called attention to characteris- 
tics of intercostal neuralgia which are important in a diagnostic point 
of view,^ and which serve to distinguish this affection from pleurodynia. 

' Valleix, op. cit. 



600 DISEASES OF THE RESPIRATORY ORGAifS. 

On carefal examination of the chest by palpation, the soreness is 
found to be not diffused, but confined to certain isolated points. 
These points, according to the observers just named, are pretty uni- 
formly three in number, viz., 1st, By the side of one or more of the 
dorsal vertebrae ; 2d, over one or more, usually two or three, of the 
intercostal spaces generally of the sixth, seventh, and eighth ribs, 
about midway between their two extremities ; and 3d, over the costal 
cartilages or in the epigastric region. The tenderness in these three 
situations is often extremely circumscribed. The points correspond 
to branches of the dorsal nerves which have a superficial distribution.^ 
Pressure on the first point, viz., by the side of the vertebral spines, is 
most constantly and in the most marked degree productive of pain. 
The frequent coexistence of this, as of other neuralgic affections, 
with tenderness on pressure over certain of the vertebrae, is a fact with 
which practitioners are familiar in this country, where the phenomena 
incident to what is usually called spinal irritation are probably more 
common than in Erance. When, as is not unusual, pressure over a 
tender portion of the spinal column provokes a paroxysm of pain in 
the affected part, and especially if the nerves distributed to the latter 
are connected with the medulla spinalis at the portion corresponding 
to the seat of tenderness, the neuralgic character of the affection is 
altogether probable. 

Shifting of the locality of the pain is another diagnostic trait. 
This is apt to occur in neuralgic and rheumatic affections, while in 
pleuritis, the pain is more fixed in the same situation. In, some 
cases of pleuralgia, the pain is seated in both sides. This is signifi- 
cant of its netiralgic or rheumatic character.^ 

But a positive diagnosis rests on the absence of the physical signs 
denoting the presence of inflammatory products within the plem*al 
sac. A well-marked intra-thoracie friction-sound is conclusive as to 
the existence of pleuritis ; but its absence is not negative proof of a 
neuralgic or rheumatic affection, for this sign is not uniformly, and, 
indeed, but rarely, discovered in the early stage of pleuritic inflam- 
mation. Acute pleuritis, however, is accompanied by more or less 
liquid effusion, giving rise to a series of physical phenomena which 
have been described. If these phenomena are not developed after a 
certaiQ time from the date of an attack of acute pleuritic pain, the 
diagnosis of a neuralgic or a rheumatic affection is settled, reasoning 

' Grisolle, PatholtMje Interne t. ii, p. 5S4. 

* A neuiaigic afiection seated in both sides is sigaificam of some lesion of the spinal 
cord. 



PLEURALGIA. 601 

by way of exclusion. In cases, therefore, in which the symptoms 
and associated circumstances leave room for doubt, it is prudent to 
defer an absolute conclusion for two or three days, when, from the 
absence of the evidence of effusion, the non-existence of acute 
: pleuritis is almost certain. The difficulty thus attending the discri- 
mination of intercostal neuralgia and pleurodynia from acute pleu- 
ritis, pertains chiefly to the dry or plastic stage of the latter affec- 
tion. So soon as it may be decided that, assuming acute inflammation 
to exist, effusion should have taken place, the differential diagnosis 
ceases to be an intricate or doubtful problem. This result, it is to be 
borne in mind, usually follows speedily the access of inflammation ; 
and it is certainly extremely rare, that an amount of effusion easily 
detected fails to occur within the first three or four days. In the 
majority of instances, probably, this is the case as early as the 
second day. 

A fact stated in connection with the subject of acute pleuritis may 
be here repeated. This disease is occasionally preceded by neuralgic 
pain in the chest, more or less severe and persisting, for several days 
before the symptoms denote an inflammatory attack. Two cases, 
illustrating this fact in a striking manner, already referred to, have 
fallen under my observation. 

It is stated by some writers that liquid effusion, and all the pheno- 
mena denoting acute pleuritis, may result from a rheumatic affection 
within the chest. This, in effect, is saying that acute inflammation 
of the pleura may be developed in connection with the morbid condi- 
tion of the system in which consists the essential pathology of rheu- 
matism. In other words, such cases, clinically, are neither more nor 
less than cases of acute pleuritis. To cases of this kind I have not, 
of course, had reference in the foregoing remarks.^ 

The occasional development of pleuritis during the course of acute 
rheumatism, is a fact to be borne in mind. The occurrence, under 
these circumstances, of the symptoms of pleurodynia, is by no means 
proof of the non-existence of veritable inflammation. Careful and 
repeated explorations of the chest are to be made, and equally in 
cases in which circumstances point to intercostal neuralgia, in order 
to determine as regards the presence or absence of the physical signs 
of pleuritis. In view of the liability to pleuritis in the progress of 

' Were discussions respecting the seat and nature of diseases embraced within the 
scope of this work, the question would arise, whether pleurodynia is not. in the sense 
in which it is practically regarded, oftener a neuralgic than a rheumatic affection, or 
both affections combined. 



602 DISEASES OE THE E,E5PISAT0RY QRGrX^s, 

zfaeoma^siEi, mthoiit tke information to be obtained by pKysical ex- 
ploirmtioi^ tke existence of in&ammatioB, as well as simple pleuro- 
dyBii% miglit be ineorrectEj inferred. It is hardly necessary to refer 
to the possibility of attributing to plenritic inflammation the pain 
soinelim^ incident to an affection of tbe heart, occurring in rheuma- 
^i^D. This would more properly bare been noticed under the head 
«rf PieiHcitis. The pcmttire digns referable to the heart, and the 
absence of the signs of inSammation of the pleura, suf&ce to obviate 
exTor witbi respect to tliis point. 

A sniiaciite but perabling neuralgic affection is Tery frequently 
met. with in females^ tibe pain referred to tke lower part of the chest 
on o®e or both sid€& It is not seyere, but of indefinite duration. 
It occurs especially in anaemic or eklorodc persons, associated fre- 
quently with ^bs&rdsat of the menstrual function, and generally with 
tenderness OTer the ^inal Textebrse. The circumstances just men- 
ticmed embsaee certain po^tire diaraeters by which it may be distin- 
; but Itbe absence of tke physical signs of intra-thoracic 
confirms its neuropathic character. 

Tke symptomatic phenomena of angina pectoris are so peculiar 
and distinctire tka^ : r rirds the possibility of confounding it with 
any otker affectio:. . : :!r to tke chest, it claims but a passing 
notice. Its paroxysn .renee; tke pain skooting in various 

directions^ and espeeiaiiy inio tke lefk iq>per extremity ; tke difficulty 
of respirationy palpitations, great anxiety, and sense of impending 
dissolution, togetker witk tke phy»cal signs of an organic affection 
of tke hearty ckaracterize this affecdon^ so as to render tke diagnosis 
srfeiently easy. 

Dliphsag-matic Hee^jta. 

In conseqa<raiee of tke eongenital absence of a portion of the dia- 
pioagniy perforatiofn by nqytore and womids, or a yielding of this sep- 
timi at certain points, and sometimes orer its whole extent on one 
ads^ ib& stomadi, intestines^ and other of tbe abdominal viscera, may 
either becontainedwidnn or encmadimoreor lesson the thoracic space. 
This franspoi^tifiii of cnrgani ^res rise to certain phenomena, dis- 
coTered by a physical eiamination of the chest. Diaphragmatic 
hernia — a term whick, with strict propriety, is applied only to pro- 
tmaian throngk tke diaphragm of parts situated below it — ^is ex- 
tremely rare, but the physician is liable at any moment to meet 



DIAPHRAGMATIC HERNIA. 603 

with an instance, although I believe no one has ever reported more 

than a single case. The very infrequencj of the affection renders it 

jj peculiarly interesting to the diagnostician ; and it is desirable for 

|i him to be prepared to recognize it, should an instance happen to fall 

: under observation. 

An affection so rare that it can hardly be expected ever to occur more 
I than once within the experience of a lifetime, must, of course, be 
|| studied by means of cases contributed by numerous observers. For 
ij this reason it has heretofore received but little attention. A distin- 
: guished American physician, Dr. Bowditch, of Boston, has recently, 
I in connection with the report of an interesting case observed by 
himself, gathered nearly if not quite all the cases contained in the 
j annals of medical literature (88 in number), and subjected them to 
Ij an elaborate numerical analysis.* The present brief consideration of 
the subject will be based on the results contained in this valuable 
paper. 
I The different varieties of diaphragmatic hernia may be classified as 
i follows : 1. When parts of the abdominal viscera are forced through 
I some one of the natural openings of the diaphragm, viz., that of the 
aorta, vena cava inferior, an intercostal nerve, or the oesophagus. 
2. When portions of the diaphragm are wanting. This results from 
an arrest of development, and is, of course, congenital. 3. Hernia 
from accidental wounds or lacerations. 4. When one side of the 
diaphragm is violently forced up into the chest, so that the lung is 
compressed, and all the signs of the affection, as seen in the other 
classes, are observed. This, strictly speaking, is not hernia, but 
from the similarity as respects the physical conditions and phe- 
nomena, it may be included in the same category. In their relative 
frequency of occurrence the four classes rank in the following order : 
(a) hernia from accidents, constituting more than one-half of the 
number of cases ; (b) from malconstruction, about one-third ; (c) 

' " Peculiar Case of Diaphragmatic Hernia, in which nearly the whole of the left side 
of the diaphragm was wanting ; so that the stomach and a great part of the intestines 
lay in the left pleural cavity; compressing the left lung, and forcing the heart to the 
right side of the sternum. This condition, evidently congenital, existed in a man who 
died at the Massachusetts General Hospital, with fracture of the spine, caused by a 
heavy blow upon it ; to which is added an analysis of most, if not all, of the cases of 
diaphragmatic hernia found recorded in the annals of medical science. By Henry J. 
Bowditch, Member of the Boston Society for Medical Observation. Presented to the 
Society in 1847." Published in the Buffalo Medical Journal, June and July, 1853 ; and 
issued by tbe author in a separate publication. 



604 DISEASES OF TEE RESPIRATORY ORGANS. 

from dilatation of natural openings, about one-twelfth ; (d) from 
diaphragm being pushed up, about one in thirty cases. 

The affection occurs much oftener on the left than on the right 
side (41 out of 59 cases) ; a disparity for which anatomical reasons 
may be offered. It is evident that the abdominal parts contained 
within the chest will be covered by the pleura and peritoneum in 
some, and not in other cases. When thus invested, the hernia is 
said to be sacculated. Sacculated hernias are vastly more frequent 
on the right than on the left side (3 only out of 11 cases of hernia 
on left side were sacculated, and 11 of 18 cases on the right side). 
The weakness of the diaphragm on the right side at a point just to 
the right of the ensiform cartilage, affords an explanation of this 
fact. The particular parts of the abdominal viscera which are con- 
tained within the chest, and the extent of the malposition, will, of 
course, depend on the situation and size of the opening. The solid 
organs, viz., the liver and spleen, as well as the hollow viscera, are 
liable to hernial protrusion. 

Strangulation at the orifice is liable to occur. The parts may pre- 
sent, or not, in cases examined after death, evidences of inflamma- 
tion, recent or more or less remote, affecting either the pulmonary 
or abdominal organs, or both. In several instances all these parts 
presented a healthy appearance. The coexistence of tubercles is 
rare. The lungs are of necessity compressed in proportion as the 
thoracic space is occupied by the abdominal viscera. Frequently 
the compressed lung, exclusive of condensation, is found to be 
healthy, and is readily inflated. Solidification from pneumonitis 
has been observed. The heart is frequently displaced, generally to 
the right. Pleuritic effusion exists in a certain proportion of cases. 

Physical Signs. — The cases on record of diaphragmatic hernia 
afford few data for determining, by means of numerical analysis, the 
physical phenomena which belong to the affection. Many of the 
cases were observed prior to the discovery of auscultation, and in 
most of those reported since that era, exploration of the chest 
during life was either performed imperfectly or altogether neglected. 
Laennec never met with an instance of the affection, but it did not 
escape his attention, and he suggested that it might be recognized 
by absence of the respiratory murmur, and the presence of borbo- 
rygmi in the chest. In the case observed by Dr. Bowditch, the signs 
were carefully noted, and in a few of the cases analyzed by him 



DIAPHRAGMATIC HERNIA. 605 

more or less of the physical phenomena were ascertained. Upon 
these facts, together with the inferences which may be rationally 
j predicated on the anatomical conditions, must rest, with our existing 
|i knowledge, an account of the physical signs. 

' Of the cases analyzed by Dr. Bowditch, in five percussion was 

; resorted to. Of these five cases dulness over the back on the affected 

side existed in four. But in three of four cases there was either 

|| pneumonitis or pleuritic effusion ; and in the fourth case the liver, 

ij colon, and omentum were embraced in a sacculated protrusion. In 

IDr. Bowditch's case percussion elicited a highly marked tympanitic 

I sonorousness. It is evident, that in proportion to the amount of the 

hollow viscera contained within the chest will be the degree and the 

I extent of the tympanitic resonance. And this resonance, both in 

degree and extent, will be likely to present at different times fluctua- 

tions dependent on the varying quantity of the stomach or intestines 

within the chest, and the greater or less distension of these parts 

I from gas. The presence of the solid organs, the liver and spleen, 

I must give rise to dulness. Liquid effusion will lead to the same 

j result. In any case, at the upper and posterior part of the chest, 

over the compressed lung, the percussion-sound will be likely to be 

dull; and the more, if the lung be solidified by inflammatory 

exudation. 

A satisfactory account of the auscultatory phenomena, with a 
I single exception, appears not to be contained in any of the cases, 
; save the one observed by Dr. Bowditch. In these two cases the 
j respiratory murmur over the greater part of the affected side was 
wanting, and on the opposite side it was exaggerated. In Dr. Bow- 
ditch's case the respiratory murmur was heard perfectly vesicular 
and pure above the second rib. 

Aside from these cases, in three a sub-crepitant rale was noticed ; 
but in all the existence of pneumonitis was found at the autopsy. 

The most significant of the signs, as anticipated by Laennec, are 
the peculiar gastric or intestinal sounds diffused more or less over the 
affected side. Dr. Bowditch describes these sounds as gurgling, 
whistling, and blowing, and although excited at times by the act of 
respiration, they were heard when the patient held his breath. 
Metallic tinkling was occasionally observed ; such as is sometimes 
heard over the stomach. Dr. Bowditch suggests that auscultatory 
phenomena may probably be produced by pressing suddenly on the 
abdomen, and thus forcing air into the intestines while in the pleural 
sac. 



606 DISEASES OF THE RESPIRATORY ORGANS. 

If the heart be displaced, the cardiac sounds will, of course, be 
transferred to an abnormal situation. 

In three of five cases in which the chest was examined by inspec- 
tion, there was more or less enlargement of the affected side. That 
this is generally incident to the affection may reasonably be inferred, 
from the large proportion of instances in which the accumulation of 
abdominal viscera within the chest is sufficient to induce great com- 
pression of the lung. In fifty-five of eighty-eight cases the lungs 
were found to be much compressed. Diminished motion or immo- 
bility of the affected side must necessarily accompany its dilatation. 
These signs will be likely to vary from time to time, in accordance 
with varying conditions as respects the amount of hernial protrusion 
and of gaseous distension of the protruded viscera. Liquid effusion 
in some cases must concur in producing dilatation and diminishing 
the mobility of the affected side. It is superfluous to add, that in 
determining these changes, mensuration, as well as inspection, may 
be employed. 

By means of palpation the abnormal position of the heart may be 
ascertained. It is probable that the vocal fremitus will be diminished 
or abolished on the affected side ; but observation has not been 
directed to this point. 

Diagnosis. — The symptomatic phenomena which are in any manner 
distinctive of the affection, relate to the r-«spiration. The analysis 
by Dr. Bowditch shows that at least three-fourths of cases of the 
different varieties of diaphragmatic hernia are characterized by more 
or less embarrassment of respiration, consisting of oppression, increased 
frequency, dyspnoea, and in one case orthopnoea. Posture has been 
observed to exert a marked influence on the symptoms referable to 
the respiration. In some instances the difficulty of breathing was 
greatly increased in the recumbent posture, which is explained by 
the tendency, from gravitation, to a greater protrusion either of the 
viscera or their contents within the chest. Irrespective of position, 
the fluctuating conditions as regards the quantity of hollow viscera 
protruding through the diaphragm, and their distension with gas, will 
account for the difficulty of breathing occurring paroxysmally, or 
being much greater at some times than at others — a fact repeatedly 
observed. But embarrassment of the respiration is not always a 
prominent symptom, even when one side of the chest is nearly filled 
with abdominal viscera. This is shown by the case reported by Dr. 
Bowditch. In this case, the patient, aged 17, was able to perform 



DIAPHRAaMATIC HERNIA. 607 

the duties of a laborer, and died, not from this affection, but from 
fracture of the spine produced by a blow from a heavy piece of 
timber. Moreover, the characters belonging to the embarrassment of 
respiration, when present, do not possess much significance. 

Judged by past experience the diagnosis would appear to be 
extremely difficult, for of all the cases collected by Dr. Bowditch the 
nature of the affection had been determined before death in but a 
single instance. This instance came under the observation of Mr. 
Lawrence, of London. In the case observed by Dr. Bowditch the 
diagnosis was made. This difficulty is, however, more apparent than 
real. From its great infrequency the affection is not suspected or 
even thought of ; and the physical signs have been but little studied, 
and are yet to be fully settled by observation. Upon the latter it is 
sufficiently clear the diagnosis depends : the existence of the affection 
can never be positively ascertained by the symptoms alone. With 
the symptoms and signs combined, Dr. Bowditch is probably correct 
in saying that " the diagnosis of diaphragmatic hernia is as easy as 
that of almost any other chronic, and possibly acute disease." 

Dyspnoea, either constant or produced by exertion, and more espe- 
cially when it comes on suddenly and as suddenly goes off, should 
suggest the idea of diaphragmatic hernia, provided it be not explicable 
by the existence of some other affection the nature of which is posi- 
tively ascertained. If the affection be congenital, in most cases more 
or less embarrassment of respiration will be found to have existed from 
birth. If due to a rupture or wound, the difficulty will date from 
some accident, which may assist in the diagnosis. In connection with 
embarrassed respiration to a greater or less extent, the following 
signs, in combination, constitute the physical characters by which the 
affection is to be recognized. Tympanitic percussion-resonance ; 
absence of respiratory murmur ; the presence of sounds identical with 
those observed over the stomach and intestines, viz., borborygmi 
and metallic tinkling, both taking place when breathing is suspended ; 
dilatation of the affected side in the majority of instances, with defi- 
cient motion or immobility, and probably absence of vocal fremitus. 

Assuming this group of signs to be present, diaphragmatic hernia 
can be confounded only with emphysema and pneumo-hydrothorax. 
The differential diagnosis from these two affections involves points 
which are sufficiently distinctive. Emphysema is generally accom- 
panied by paroxysms of asthma, the symptomatic characters of which 
will serve to distinguish it. It is accompanied by more or less cough 
and expectoration, these symptoms being only occasionally present 



608 DISEASES OF THE RESPIRATORY ORGANS. 

in diaphragiriatic hernia. But physical exploration in emphysema 
shows a sonorousness not purely tympanitic, but vesiculo-tympanitic ; 
dilatation and deficient motion especially marked at the upper part 
of the chest in the majority of instances ; bronchial rales or a modi- 
fied respiratory sound generally more or less diffused, together with 
the absence of borborygmi and metallic tinkling. 

Pneumo-hydrothorax in nine cases out of ten is suddenly dereloped 
as the result of perforation of the lung in the course of phthisis, the 
existence of which has been established. Or it occurs from perfora- 
tion taking its point of departure from within the pleura, in the 
course of chronic pleuritis, the latter affection having been previously 
ascertained to exist, if the case have been under observation. It is 
only in cases in which these antecedents cannot be ascertained, that 
diaphragmatic hernia is to be suspected. As respects physical signs, 
the two affections are in several respects similar. Tympanitic reso- 
nance, absence of respiratory murmur, dilatation and deficient mo- 
bility, abolition of fremitus, and displacement of the heart, are com- 
mon to both. But each affection has its positive signs. In the 
majority of cases of pneumo-hydrothorax metallic tinkling occurs in 
connection with the respiration, voice, and cough ; and in many in- 
stances the cavernous and amphoric respiration and voice are present. 
The succussion-sound may be pretty uniformly produced. Absence of 
fluctuation is often discovered. In diaphragmatic hernia borborygmi 
constitute a positive and strikingly peculiar sign ; and tinkling or 
amphoric signs are found to occur, not in synchronism with acts of 
breathing, speaking, or coughing, and irrespective of the movements of 
the body. The discrimination must be based on the presence of the 
latter phenomena, and the absence of the signs and the circumstances 
relating to the previous history, which characterize pneumo-hydro- 
thorax. 

Farther clinical observation of diaphragmatic hernia, especially as 
respects the results of physical exploration, may lead to the know- 
ledge of new diagnostic points, which cannot now be foreseen. At a 
future period some one, imitating the zeal and industry of Dr. Bow- 
ditch, will be able to gather together and analyze an extended series 
of cases, in which the signs, as well as symptoms, have been carefully 
observed and noted ; but in the meantime it is important that the affec- 
tion be recognized, not merely for the gratification afforded by skiU 
in the diagnosis of rare and curious forms of disease, but because 
much may be done by judicious management to contribute to the 
comfort and safety of the patient. 



CHAPTER VIII. 

DISEASES AFFECTINa THE TRACHEA AND LARYNX— FOREIGN 
BODIES IN THE AIR-PASSAGES. 

In its application to the diagnosis of traclieal and laryngeal affec- 
tions, physical exploration is far less important than when the lungs 
are the seat of disease. The symptomatic phenomena belonging to 
pulmonary affections are never to be dissociated, clinically, from 
the physical signs, but, relatively, the latter are in general much 
more distinctive and reliable. It is otherwise in diseases affecting 
the air-passages above the bifurcation of the trachea. Here the 
symptoms are mainly to be relied on, the results of physical exami- 
nation holding a comparatively subordinate rank. This being the 
case, I shall not, as hitherto, consider the different affections in- 
cluded in this group under separate heads, but refer to them, indivi- 
dually, in an incidental manner, in treating of the general application 
of the principles and practice of physical exploration to diseases 
affecting the trachea and larynx. Another reason for pursuing this 
course is, the same physical signs will be found to be common to 
different affections, and the general principles regulating the prac- 
tice of exploration are in a great measure applicable alike to all. 

Of the different methods of examination, auscultation is alone 
adapted to the investigation of morbid conditions seated in the 
trachea or larynx. Dr. Stokes has suggested that percussion may 
in some instances furnish results worthy of attention.^ He does not, 
however, present any facts illustrative of its value in this application. 
The inventor of mediate percussion, and the ardent advocate of its 
capabilities, Piorry, assigns to it a very limited scope of availability 
in these affections. He claims in behalf of this method, that it may 
sometimes be useful in determining the precise line of direction of 
the trachea and larynx, when they are buried beneath or imbedded 
in a large tumor on the neck. The percussion-sound may also afford 
some aid in estimating the distance of the tube from the surface. 

I Diseases of the Chest, etc. 
39 



610 DISEASES OF THE RESPIRATORY ORGANS. 

An amphoric resonance, attributed by Piorry to the presence of air 
and liquid, he thinks denotes the presence of secretions in this situa- 
tion ; but this view of the significan*ce of the sound is, as already 
stated, more than questionable. Finally, in a case of subcutaneous 
emphysema, in which very marked resonance exists over the neck, 
there is ground for the suspicion that rupture of the larynx has 
taken place, giving exit to air into the surrounding areolar tissue.^ 

The discoverer of auscultation attached very little importance to 
the application of this method to the diseases of the windpipe. Of 
those who since the time of Laennec have given special attention to 
physical exploration, few have deemed this branch of the subject 
deserving of consideration ; and the sum of what is at present actually 
known, is probably embraced in the writings of Dr. Stokes,^ and in 
two papers contributed by M. Barth, of Paris.^ The materials for 
the few remarks which are to follow, will be chiefly obtained from 
the sources just referred to. 

Physical exploration, in diseases affecting the trachea and larynx, 
admits of a direct and indirect application. By the term direct, I 
mean to refer solely to auscultation of the windpipe. The foregoing 
remarks have related to physical exploration as thus restricted. 
Indirectly, the physical exploration of the chest is applicable, in 
order to determine whether pulmonary disease coexists or not. The 
importance of physical signs is much greater in the latter than in 
the former application. Indeed, the examination of the chest in 
connection with diseases affecting the trachea and larynx is often 
of very great importance. We will consider first, direct exploration ; 
in other words, the physical signs developed by auscultation of the 
trachea and larynx ; and, second, indirect exploration, or the exami- 
nation of the chest in the investigation of diseases seated in these 
parts. 

1. Auscultatio7i of the Trachea and Larynx. — The results ob- 
tained by auscultation in health have been considered in Part I.'* 
Briefly, also, the adventitious sounds or rales produced in this situa- 
tion, have been adverted to.^ It remains to notice here the relations 
of pathological phenomena to the different forms of disease. The 

* Traite Pratique d'Auscultation, etc., par Barth & Roger, 1854, p. 704. 

* On Diseases of the Chest. 

3 Archives Generales de Meilecine, Juillet, 1838, et Juin, 1839; also. Traite Pratique 
d"Auscuhation, etc. par Barth and Roger, 1854, p. 255. 

* Vide page 137. ^ Vide page 217. 



DISEASES AFFECTING THE TRACHEA AND LARYNX. 611 

anatomical conditions, giving rise to auscultatory signs, are the fol- 
lowing. 1. Diminution'of the calibre of the tube, either at certain 
points, or, in some instances, over its whole extent. This occurs in 
connection with various affections, viz., swelling of the lining mem- 
brane and submucous infiltration in laryngitis ; oedema of the areolar 
tissue above the vocal chords (oedema glottidis) ; spasm of the glottis 
and laryngismus stridulus (false croup) ; the exudation of lymph on 
the mucous surface (true croup) ; accumulation of viscid adhesive 
mucus ; tumefaction of the margins of ulceration ; vegetations or 
morbid growths, and the pressure of an aneurismal or other tumor. 
2. Loss of substance by ulceration from tuberculous or syphilitic 
disease. 3. Membranous deposit becoming loose and partially de- 
tached, and a pedunculated polypus admitting of change of position. 
4. Accumulation of liquid, mucous, purulent, serous, or bloody. The 
presence of foreign bodies will be noticed under a distinct head. 

Contraction of the space within the tube from the several causes 
just enumerated, may give rise to abnormal modifications of the respi- 
ratory sound, consisting of augmented intensity, roughness of quality, 
and marked elevation of pitch, or adventitious vibratory sounds (dry 
rales) may be developed. The latter may be on a high or low key, 
and they frequently have a musical intonation. They represent, on 
an exaggerated scale, the bronchial sibilant, and sonorous rales. 
They are often sufficiently loud to be heard at a distance, constituting 
stridor or stridulous breathing, but when not thus apparent they may 
be discovered with the stethoscope applied over the larynx or trachea. 
Do these diversities of modified and adventitious respiratory sounds 
possess, respectively, special diagnostic significance ? Observation, 
as yet, has furnished but little ground for an affirmative answer to 
this question. They appear to belong alike to the diff"erent forms of 
disease, inducing the same anatomical condition, viz., diminution of 
the calibre of the tube. Barth has observed, in some cases of laryn- 
geal ulcerations with tumefied borders, involving obstruction, a pecu- 
liarly loud sonorous rale (cri soiiore) in inspiration, giving the impres- 
sion of the rapid passage of air through a narrow orifice, which he 
regards as distinctive of the morbid condition just mentioned. It is, 
however, difficult to obtain from his description, a very clear idea of 
the special character of sound to which he refers. The same observer 
thinks that a sonorous rale, presenting a strongly marked metallic 
quality, like a sound produced within a tube of brass, is heard 
oftener in croup than in other aff'ections which diminish the calibre 



612 DISEASES OF THE EESPIRATORY ORGAN'S. 

1 

of the windpipe. Stokes describes a rale produced within the larynx, 
resembling " the raj^id action of a small Talve, combined with a deep 
humming sound,"^ which he regards as peculiar and quite character- \ 
istic of chronic laryngitis with ulceration. He states that this rale 
may exist on one side of the larynx without being perceptible on the | 
other, its situation perhaps corresponding to a circumscribed ulcera- 
tion. With reference to this sign, the same remark is applicable as 
to the loud sonorous rale [cri sonore) above mentioned. In both in- 
stances, the data are insufficient to establish a pathological signifi- 
cance. It is not improbable that farther clinical study may lead to 
distinctive characters pertaining to particular sounds. As already 
intimated, I have nothing to contribute to this branch of the subject 
from my own observation. 

The situation of the auscultatory signs which have been mentioned, 
may furnish information as to the seat of the disease and its extent. 
They may be limited to a small space. If they are persistingly 
heard in the same spot, there is reason to suppose that the local 
affection is thus circumscribed. This may possibly be found to be 
useful, with reference to the feasibility of making topical applications, 
and may serve as a guide in the direction of the instrument used 
for that purpose to the proper place. If the abnormal sounds be 
not thus localized, they may be found to present at some point, dis- 
tinctly, a maximum of intensity. This may equally indicate either 
the seat of the disease, or the point at which it is greatest in amount. 
To serve as a guide to the locality of disease, the abnormal sounds 
must be repeatedly or constantly found to be circumscribed, or to 
have their maximum of intensity well defined and in the same situa- 
tioD, for in certain instances the sounds are due to transient physical 
conditions, viz., spasm, or the accumulation of viscid mucus. The 
laryngo-tracheal sounds are sometimes so intense and diffused as to 
be transmitted over the chest, obscuring the pulmonary sounds and 
liable to be mistaken for the latter. This source of error has been 
already referred to. 

A tremulous, flapping sound {tremhlotement) has been observed by 
Barth in cases of croup, at a period of the disease when it was sup- 
posed to indicate a loosened and partially detached condition of the 
false membrane. He regards this sign as affording valuable informa- 
tion in cases of croup, denoting, in the first place, progress in the 

' Dr. C. J. B. Williams suggests that the hi;mming sound may have been produced in 
the jugular vein. (On Diseases of the Respiratory Organs. American ed. 1845, p. 131.) 



DISEASES AFFECTING THE TKACHEA AND LARYNX. 613 

processes by which the exudation is detached ; and, in the second 
place, enabling the auscultator to judge respecting the extent over 
which the exudation is diiFused. If the rale be limited to the larynx, 
it is a favorable sign, showing that the false membrane is probably 
confined to this part, and that the conditions are favorable for its 
speedy removal by expectoration ; but if it extend over the trachea 
and especially to the bronchi, the prognosis is rendered unfavorable 
by this evidence of the extension of the disease. 

Theoretically, we may suppose that a pedunculated tumor within 
the larynx or trachea, moving to and fro in the respiratory acts, 
might occasion a sound of friction, which, taken in connection with 
the symptoms, should render probable the nature of the affection. 
In a case reported by M. Ehrmann, of Strasburg,* a valvular sound 
{bruit de soupape), was heard distinctly in a forced respiration. 

Erosive ulcerations, which sometimes destroy, to a greater or less 
extent, the vocal chords, it may be presumed must give rise to modi- 
fications of the respiratory sound, more especially in expiration, by 
enlarging the space at the glottis. The contraction at this point, 
from the approximation of the chords in the expiratory act not taking 
place, one of the conditions upon which probably depend, in health, 
the intensity and elevation of pitch of the laryngo-tracheal sound in 
expiration, is wanting; and under these circumstances it may be anti- 
cipated that this sound will become relatively feeble and low in pitch. 
This is an interesting point to be settled by observation. 

The foregoing remarks have had reference to abnormal modifications 
of the respiratory sounds together with dry or vibrating rales. Bub- 
bling or gurgling sounds attest the presence of liquid in the trachea 
and larynx. Owing to the size of the tube, and the force of the 
column of air which traverses it in respiration, the presence of a 
considerable accumulation of mucus, or other liquid, is indicated by 
loud rales, heard at a distance, and commonly known as the tracheal 
rattle, or (since such an accumulation very rarely takes place except 
toward the fatal termination of disease), the " death rattle." These 
sounds are not distinctive of any affection of the windpipe ; they de- 
note deficient sensibility and loss of muscular power to such an extent, 
that either efforts are no longer made or they prove insufficient to 
expel the accumulated matter by expectoration. But moist rales 
may be discovered in some instances by stethoscopic examination 
when they are not apparent at a distance, and to some extent they 

' Valleix, op. cit. 



614 DISEASES OF THE RESPIRATORY ORGANS. 

may be made available in diagnosis. Thus it is suggested b j Piorr j , 
that in certain cases of hsemoptysis, a humid rale localized in the 
larynx, provided no rales are found at the lower part of the trachea 
and over the pulmonary organs, is evidence that the hemorrhage has f 
taken place from within the larynx.^ Again, Barth and Roger state f 
that in cases of ulcerations in the larynx, a gurgling or bubbling sound 
found at a particular part of the organ, may point to the seat of these 
ulcerations, or the maximum of the intensity of the sounds may indi- r 
cate the side on which the ulcerations are most numerous and exten- 
sive. These sounds are most likely to be produced, and to be avail- 
able in localizing ulcerations, when the latter are situated at the 
bottom of the ventricles of the larynx. 

In conclusion, auscultation in affections of the trachea and larynx 
furnishes certain physical phenomena, but, with our present know- 
ledge, these phenomena embrace very few characters which are dis- 
tinctive of particular forms of disease. They show the calibre of the 
tube to be diminished, but not the cause of the contraction, nor do 
they, in general, afford definite information as to the amount of 
obstruction. The latter point is determined, as will be seen presently, 
much better, indirectly, by an examination of the chest. They show 
the presence or absence of liquid ; and in croup, information may 
sometimes be obtained which is of aid in forming an opinion as to 
the condition of the false membrane, and the distance to which it 
extends below the larynx. The seat of inflammation or ulceration 
may in some cases be ascertained, by finding that the morbid pheno- 
mena are persistingly fixed in a particular part, perhaps even confined 
to one side of the larynx ; or, if more extended, by observing that at 
a certain point sounds have distinctly a maximum of intensity. 
These few words comprise the summary of what is actually known. 
The other points mentioned in the preceding remarks require to be 
confirmed by farther observation. It is by no means improbable that 
clinical investigations may hereafter develope facts, which will render 
the direct application of physical exploration to the diagnosis of dis- 
eases affecting the trachea and larynx of much greater importance 
than it is with our present knowledge of the subject. 

2. Examination of the chest in the investigation of diseases affect- 
ing the trachea and larynx. — Examination of the chest in cases of 
laryngo-tracheal affections, as already remarked, is of much impor- 

^ Barth and Roger, op. cit. p. 263. 



DISEASES AFFECTING THE TRACHEA AND LARYNX. 615 

tance. Grave errors of diagnosis may be thereby avoided. Lobular 
pneumonitis and capillary bronchitis are sometimes mistaken for 
croup, and treated with repeated emetics and topical applications to 
the larynx, when the phenomena revealed by thoracic exploration 
would show the existence of these affections. It is true that the 
existence of one or the other of these affections does not constitute 
conclusive proof that croup does not exist, for they are sometimes 
associated with the latter. Taken in connection, however, with other 
points, the greater importance of which will be admitted, they are to 
be taken into account as affording an adequate explanation of certain 
of the symptoms which might otherwise be referred to the larynx. 

To determine whether pulmonary disease coexists, or not, with an 
affection of the trachea or larynx, is a grand object in examining the 
chest. In cases of the affection just cited, croup, it is very desirable 
to settle this point, with reference to the prognosis, to the treatment 
to be pursued, and especially when it becomes a question as to the 
propriety of resorting to tracheotomy. The advantages of this know- 
ledge in these relations is sufficiently obvious. 

In cases of chronic laryngitis, the question arises as to its coexist- 
ence with tuberculous disease of the lungs. Pathological observa- 
tions have established the fact that in the vast majority of cases the 
laryngitis is a complication of an antecedent pulmonary tuberculosis, 
and that the laryngeal affection is, in fact, tuberculous. But this 
rule is not invariable. The affection may have a syphilitic origin. 
The law of probabilities will not then suffice for the diagnosis ; and 
the symptoms are not alone adequate to settle the question, the more 
because the most prominent, viz., the cough and expectoration, may 
be attributed to the laryngitis. It is not uncommon for practitioners 
who do not avail themselves of physical exploration, in cases of 
phthisis complicated with laryngitis, to persuade themselves and their 
patients that the disease is seated exclusively within the larynx. It 
is by means of the precision given to the early diagnosis of pulmonary 
tuberculosis, that the consecutive occurrence of the laryngeal affection 
has been established, and that an extension of disease from the larynx 
to the lungs, as implied in the term laryngeal phthisis, very rarely, 
if ever takes place. A persisting chronic laryngitis, then, warrants 
a strong presumption of a deposit of tubercle in the lungs, but the 
proof positive is the evidence afforded by the presence of the physical 
signs revealed by an examination of the chest. On the other hand, 



616 DISEASES OF THE RESPIEATORY ORGAN S. 

the non-existence of tubercle is to be inferred from the negative 
results of physical exploration. 

The syphilitic origin of a laryngeal affection may in some instances 
be inferred in connection with the results of an examination of the 
chest. This conclusion may be reasonably entertained, when the 
affection is found not to be associated with pulmonary tuberculosis, 
and the patient is known to have been affected with syphilis. 

Another grand object to be attained by an examination of the 
chest in the various forms of disease affecting the trachea and larynx, 
is to determine the actual amount of obstruction to the passage of air. 
This important point can be settled vastly better by an exploration of 
the chest than by auscultation directly of the windpipe, and fre- 
quently more satisfactorily than by the symptoms. The evidence of 
the amount of obstruction is the degree of diminution or the suppres- 
sion of the vesicular murmur. This diminution or suppression, when 
the obstruction is seated in the trachea or larynx, will, of course, be 
uniform on the two sides of the chest. In fact, the existence of some 
affection of the air passages above the tracheal bifurcation is to be 
suspected, even should the symptoms not point to disease in that 
direction, if the vesicular murmur is found to be equally diminished 
on both sides in a notable degree, or suppressed, provided the phy- 
sical signs of emphysema of the lungs are wanting. The error of 
attributing the diminution or suppression of the vesicular murmur, 
due to an obstruction above the tracheal bifurcation, to emphysema, 
is to be guarded against by attention to the other signs, which serve 
by their presence or absence to establish or exclude that affection. 
Whatever may be the disease which diminishes the calibre of the 
windpipe, so long as the vesicular murmur continues to be tolerably 
developed, the patient is not in immediate danger from suffocation, 
notwithstanding the manifestations or expressions of suffering. The 
progress of the disease, as regards its dangerous effects, may thus be 
ascertained from time to time, and the fact of an actual improvement 
may be established more positively by an increased development of 
the vesicular murmur than by an apparent relief from the labor and 
distress attending respiration. In acute or dangerous affections, then, 
of the larynx, viz., acute laryngitis, croup, and oedema of the glottis, 
vastly more importance belongs to auscultation of the chest than of 
the larynx itself ; and, in fact, the predictions of the physician, his 
hopes and fears, as well as the therapeutical measures which he 



DISEASES AFFECTING THE TRACHEA AND LARYNX. 617 

employs, must be influenced in no small measure by tlie pulmonary- 
signs. 

Exploration of the chest assists the auscultator in determining 
whether an obstruction seated in the larynx be due either exclusively 
or in part to spasm of the glottis, or whether it depends entirely on 
a diminution of the calibre from a physical cause, such as cedema, 
exudation of lymph, or submucous infiltration. In the former case, 
the diminution or suppression of the vesicular murmur will be inter- 
mittent or variable ; in the latter, it will be more persisting and 
uniform. Thoracic auscultation thus affords valuable aid in making 
the differential diagnosis of spasm of the glottis from other and far 
more serious affections, with which there is some liability of its being 
confounded. Moreover, spasm of the glottis forms an important 
element in other affections of the larynx, viz., laryngitis, true 
croup, and perhaps oedema. The extent to which the symptoms of 
suffocation are due to this element, may be fairly estimated by the 
development of the vesicular murmur under the circumstances in 
which relaxation of spasm occurs ; for example, directly after a fit 
of vomiting. It is important to determine how much of the obstruc- 
tion arises from spasm ; not only in order to form a correct opinion 
as to the immediate danger, but with a view to therapeutical measures. 
In proportion as spasm predominates, are the indications present for 
remedies addressed to this element of the affection. 

Dr. Stokes has pointed out a method, available in certain cases, 
by which pressure on the trachea of an aneurism, or other tumor, 
may be distinguished from laryngeal obstruction. In the former 
case it frequently happens that the direction of the pressure is upon 
one of the bronchi, before extending to the trachea ; and if explora- 
tion of the chest be practised while the effect is limited to the 
bronchus, the consequent diminution or suppression of the vesicular 
murmur will be confined to the corresponding side of the chest. 
Subsequently, when the tumor increases sufliciently to diminish the 
calibre of the trachea, the vesicular murmur is lessened or lost on 
both sides. On the other hand, an obstruction seated in the larynx 
or in the trachea, will, from the first, affect equally the vesicular 
murmur on the two sides. Diminution or suppression of the vesi- 
cular murmur, then, first on one side, and afterwards extending to the 
other, provided pulmonary disease and the presence of a foreign 
body in the air-passages are excluded, indicates an aneurismal or 



618 DISEASES OF THE EE5P1BAT0RT ORGANS. 

Other tumor, originating below the hifbrcation, and extending gradu- 
allj upward. 

To recapitnlate the several points of view in which an examina- 
tion of the chest is nsefnl, in the investigation of diseases affecting 
the trachea and larynx, it may prevent the error of attributing to a 
morbid condition of the windpipe, phenomena belonging to a pulmo- 
nary affection : it enables the physician to determine whether, or 
not, a laryngo-tracheal affection, e, g. croup, is complicated with a 
disease of the lungs, which will influence the prognosis and treat- 
ment; it furnishes evidence, or otherwise, of the coexistence of 
pulmonary tuberculosis with chronic laryngitis, and, by its negative 
results, may warrant the conclusion that the laryngeal affection is 
syphilitic ; it furnishes the most reliable index of the amount of 
obstruction incident to the various forms of disease which diminish 
the calibre of the laryngo-tracheal tube, and it affords evidence that 
the deficiency of respiration proceeds from an obstruction in the 
tube, and not from a morbid condition of the pulmonary organs: it 
is a means of ascertaining whether an obstruction be due to spasm, 
and in cases of affections wbich involve a spasmodic element, of 
estimating the relative importance attributable to this element; and 
it supplies a method of distinguishing, in some cases, an aneurism or 
other intra-thoracic tumor, extending upward and making pressure 
on the trachea, from an obstruction seated in the larvnx. 



EoEEiGsr Bodies ln' the Aie-Passages. 

Foreign bodies occasionally slip from the pharynx into the orifice 
of the larynx. This accident is not very infrequent, occurring 
oftener in children than in adults. The bodies which have been 
known thus to become lodged in the windpipe, form a heterogeneous, 
motley collection — ^morsels of food, coins, grains of com. seeds of 
various kinds, nuts, teeth, bullets, nails, etc. etc. Their size is 
often greatly disproportionate to the aperture at the glottis as ob- 
served in the dead subject, so that it has been difficult to account for 
the manner in which they gain entrance into the air-passages. This 
difficulty is removed by our present knowledge of the respiratory 
movements of the glottis. It has been fully demonstrated that dila- 
tation and contraction of the space at the glottis occur in regular 
alternation during the respiratory acts, the first in inspiration and 






FOREIGN BODIES IN THE AIR-PASSAGES. 619 

the second in expiration. When dilated with the act of inspiration, 
the size of the rima glottidis is nearly double that which it has in a state 
of rest.^ Now it is in the act of inspiration, at a moment when the 
epiglottis fails to protect the laryngeal opening, that the foreign 
body is drawn into the air-tube instead of passing down the oeso- 
phagus. The approximation of the vocal chords with the consequent 
contraction of the outlet in the expiratory act, and still more in the 
act of coughing, constitutes an obstacle to the expulsion of the for- 
eign body after it gains admission into the windpipe, and hence, in 
a large proportion of cases, a surgical operation becomes necessary 
to eifect its removal. 

The presence of a foreign body in the air-passages gives rise to 
serious effects, according to its situation, size, form, and character. 
More or less disturbance of respiration, and disease of the air-tube or 
lungs, almost inevitably follow. Frequently it occasions great ob- 
struction to the passage of air, and not infrequently, unless speedy 
relief be obtained, it proves fatal by inducing asphyxia. The reader 
is referred to the valuable monograph by Prof. Gross for a digest 
and analysis of nearly all the cases that are to be found in the annals 
of medicine, in addition to those occurring under his own observation 
and communicated to him by his professional friends, together with 
deductions pertaining to the effects, symptoms, diagnosis, and treat- 
ment of this accident.^ 

Physical exploration furnishes frequently important information in 
cases of foreign bodies in the air-passages. 1. It assists in deter- 
mining the fact of the presence of a foreign body, in some instances 
where it is a matter of question whether the symptoms are due to 
this cause or to a morbid condition. Cases have been reported in 
which patients with a foreign body in the windpipe have been 
treated for croup, ordinary laryngitis, and spasm of the glottis ; 
and, on the other hand, in cases of these affections the presence of a 
foreign body is sometimes suspected. The importance, in a practical 
point of view, of settling this question is sufficiently obvious. In the 
former instance, there is great danger that life will be lost for the 
want of proper surgical interference ; in the latter instance, a severe 
and dangerous operation may be needlessly performed, and other 
inappropriate measures of treatment resorted to. 2. It indicates the 

^ Vide Introduction, page 52. 

2 ^ Practical Treatise on Foreign Bodies in the Air-passages, by S. D. Gross, M.D, 
Professor of Surgery in the University of Louisville, etc. 1854. 



620 DISEASES OF THE RESPIRATORY ORGANS. 

situation of the foreign body, vrhether in the larynx, trachea, or one of 
the bronchi. A foreign body may be lodged in each of these situations,- 
and the relative proportion of instances in which it is found in each, 
is a point of importance with reference to the diagnosis. Of 21 cases 
proving fatal without a sui'gical operation, which were analyzed by 
Prof. Gross,^ in 11 the foreign body was found in the right bronchus ; 
in 4 within the larynx ; in 3 within the trachea ; and in 1 partly 
within the larynx and in part within the trachea. In no instance 
was it found in the left bronchus ; but examinations made during life 
show that it does occasionally become fixed in that situation. The 
fact that in the vast majority of instances it falls into the right 
rather than the left bronchus, is to be borne in mind. The anato- 
mical reasons for this fact, which are fully presented by Prof. Gross, 
have been already mentioned.^ 3. The physical signs show the 
changes in the situation of the foreign body which are liable to occm\ 
Prof. Gross states that in several instances falling under his own 
observation a change of place occurred, and in one case it was trans- 
ferred from the right to the left bronchus. The same fact has been 
observed by others. The movableness of the body may also be ascer- 
tained by physical exploration ; and this is an important point with 
reference to the probability of its being removed by a surgical opera- 
tion. It has been known to become permanently fixed and encysted 
at some point in the air-passages. 4. The effect produced on the 
respiratory function, as determined by auscultation, authorizes an 
opinion as to the size of the foreign body, or, at all events, it shows 
the amount of obstruction which it produces, and the consequent im- 
mediate danger. 

Physical exploration in cases of foreign bodies, as in diseases affect- 
ing the trachea and larynx, may be said to have a direct and an in- 
direct application. Using these terms in the same sense as heretofore, 
in its direct application it -furnishes certain signs emanating from 
the windpipe itself; indirectly, it ascertains the phenomena which 
represent the effects produced on the lungs. Here, also, as in dis- 
eases affecting the trachea and larynx, the information obtained by 
an examination of the chest is often much more important than that 
derived from direct exploration of the windpipe. Proceeding to notice 
the physical signs, we will consider them in the order just mentioned, 
but without a formal division. 

Percussion over the trachea or larynx is of little or no avail, but, 

' Op. cit. p. 49. 2 Introduction, p. 48. 



FOREIGN BODIES IN THE AIR-PASSAGES. 621 

in addition to auscultation, palpation is sometimes resorted to with 
advantage. Mainly, however, auscultation is to be relied upon, so far 
as physical exploration, in its direct application, is concerned. In 
auscultating both the windpipe and the chest, much difficulty will be 
likely to be experienced, in children, from their resistance, and the 
restlessness occasioned by their distress. Prof. Gross suggests, that 
to secure a satisfactory exploration, chloroform may with propriety 
be employed. The objections to this measure, if there are any, are 
yet to be ascertained by experience. 

A dry rale may be produced at the point of lodgment of the foreign 
body, which may present either the sonorous or sibilant character. 
This sign was observed in several of the cases analyzed by Prof. 
Gross. The sound is described by different observers as ivhizzing, 
whistling^ cooing, whiffing, l^uffing, and snoring. These terms, with 
the exception of the last, denote a high-pitched or sibilant rale. 
Diversities in the audible characters are unimportant. The intensity, 
pitch, or quality of the sound give to it no special significance. The 
practical importance of the rale consists, first, in the fact of its ex- 
istence, and, second, in its being either limited to a particular part 
of the windpipe, or the maximum of its intensity being found at a 
certain point. The situation of the foreign body, it may be pre- 
sumed, corresponds to the part where the rale is heard, or where it is 
most intense, especially if other signs, to be presently referred to, are 
in accordance with this conclusion. Thus, the rale may be observed 
only over the larynx, or if it be sufficiently loud to be propagated 
downward, it may be decidedly more intense over the larynx. The 
same may be true of the trachea ; but in the vast majority of in- 
stances, if the foreign body be not detained in the ventricle of the 
larynx, it becomes lodged in one of the bronchi, and almost invariably 
in the right bronchus. A rale may then be heard near the sterno- 
clavicular junction on one side, or more marked in that situation on 
one side than on the other, indicating the bronchus in which it is 
situated. A curious phenomena was observed in a case reported by 
Prof. Macnamara, of Dublin.^ A boy while occupied in whistling 
through a plum stone, perforated on each side, and the kernel removed, 
by a strong inspiration drew the stone into the larynx, where it be- 
came fixed transversely, without occasioning much inconvenience for 
several days. During this period the passage of the air through the 
perforation produced a sound as when the stone was placed across 

' Gross on Foreign Bodies, p. 110 : Stokes on tlie Chest, p. 253. 



622 DISEASES OF THE EESPIRATOKY ORGAXS. 

the lips, and the boy for some hours went about pleased with this 
novel and convenient method of whistling. The stone was localized 
by means of this sound, and an operation performed. The trans- 
ference of a rale from one part to another, warrants a suspicion of a 
change of place of the foreign body ; but this point, as will be seen 
presently, is ascertained more positively by an examination of the 
chest. If the foreign body be lodged in one of the ventricles of the 
larynx, it is not improbable that the presence of a rale on one side 
and not on the other, or a greater intensity of the sound on one side, 
may indicate in which of the ventricles it is situated. 

"When the foreign body remains in a certain position for some 
time, it produces local irritation, inflammation, or even ulceration of 
the mucous membrane. A moist or mucous rale may then become 
developed ; and the same inferences are to be drawn from its being 
limited to one part, or from the maximum of intensity being local- 
ized, as in the case of a dry or vibrating rale. If the foreign body be 
lodged in one of the bronchi, inflammation is apt to extend to the 
bronchial subdivisions, giving rise to bronchial rales, either dry or 
moist, or both combined, over the chest, to a greater or less extent, 
on the corresponding side. 

A flapping or valvular sound on auscultating the trachea and 
larynx, has been observed in some instances, due to the movements 
of the foreign body to and fro in the tube, by the current of air in 
the respiratory acts. The shock occasioned by the impulsion of the 
substance against the vocal chords in acts of coughing has also been 
found to be distinctly appreciable by the touch. And it is in such a 
case that palpation may prove a valuable method of exploration. In 
a case reported by the late Mr. Bransby B. Cooper, this tactile sign 
was so well marked in a boy who had inhaled a pebble into the wind- 
pipe, that the presence of the foreign body was predicated mainly 
upon it, the symptomatic phenomena being slight, and an operation 
successfully resorted to.^ It is of course only in certain cases that 
this sign is available ; but when present, it is highly significant of a 
hard, movable substance, like a pebble or shot, within the trachea. 

An examination of the chest often affords evidence of the presence 
of a foreign body, and of its situation, more definite and reliable 
than the signs obtained by direct exploration of the windpipe. As 
already remarked, the results of the former of these two applications 
of physical exploration is much the more important. The pulmonary 

' Gross on Foreign Bodies, etc, p. 111. 



FOREIGN BODIES IN THE AIR-PASSAGES. 623 

phenomena are made to supply positive proof with reference to the 
points just mentioned, bj a simple process of reasoning. If a foreign 
body be lodged within the larynx or trachea, in proportion as it pre- 
sents an obstacle to the passage of air, the vesicular murmur will be 
rendered feeble, or it may be suppressed ; and assuming that there 
exists no affection of the lungs, the percussion-sound not only remains 
undiminished, but it may even be increased. Under these circum- 
stances, the diminution or suppression of the vesicular murmur, co- 
existing with a clear resonance on percussion, will be found equally 
on both sides of the chest. Now, if it be known that a foreign body 
is contained somewhere within the air-passages, the combination of 
signs just stated, viz., the vesicular murmur diminished or suppressed 
equally on both sides, and a clear percussion-sound, indicates with 
positiveness that it is situated above the bifurcation, either within the 
trachea or larynx. But we will suppose that the presence of a 
foreign body is not known, and the question is as to the diagnosis, 
being assured that the lungs themselves are free from disease, and 
assuming that there has suddenly occurred marked diminution or sup- 
pression of the vesicular murmur, the inference is positive that either 
there is a foreign body in the windpipe, or that there exists some disease 
of the laryngo-tracheal tube which involves obstruction, such as acute 
laryngitis, oedema glottidis, spasm of the glottis, or croup. We have 
then only to decide from the history and symptoms that none of these 
affections are present, in order to reach, by way of exclusion, the 
fact of the existence of a foreign body. The differential diagnosis 
of a foreign body in the larynx or trachea from the different diseases 
seated in the windpipe, is to be based on the vital phenomena and 
pathological laws which characterize respectively these diseases. To 
consider the distinctive points would render it necessary to treat of 
their diagnostic features. It must suffice to say that, in discriminating 
between them and the presence of a foreign body, they are to be ex- 
cluded, and the characteristics derived from symptoms and patho- 
logical laws which belong to each, are, in general, sufficiently con- 
stant and striking to constitute, when present, evidence of its 
existence, and, conversely, w^hen absent, to warrant its exclusion. In 
one of the affections named, viz., oedema glottidis, the touch is often, 
if not generally, available as a means of diagnosis. 

But in a large majority of instances, the foreign body does not 
remain in the larynx or trachea. It becomes lodged in one of the 
bronchi, generally the right bronchus. In this situation, according 



624 DISEASES or the respiratory organs. 

to its size and form; it produces either more or less obstruction, or 
complete occlusion of the bronchial tube. In proportion to the 
amount of obstruction, the vesicular murmur on the corresponding 
side will be diminished, and if there be occlusion, the murmur will 
be suppressed. If the lung be free from disease, the percussion- 
resonance will continue unaffected, unless the occlusion lead to more 
or less collapse of the lung. The latter effect, it is stated, may 
follow, and then there will be dulness in proportion as the volume 
of the lung is diminished, together with contraction and lessened 
mobility of the affected side.^ This, however, is probably only an 
occasional result. The respiratory function of the lung on the oppo- 
site side will be increased, giving rise to a vesicular murmur, exag- 
gerated in proportion as the function of its fellow is compromised. 
Here, then, we have an assemblage of pulmonary signs which point 
with certainty to the situation of the foreign body, assuming its 
presence in the air-passages to be known. A vibrating rale, heard 
exclusively, or with its maximum of intensity, over the bronchus, is a 
confirmatory physical sign. The same may be said of a mucous rale, 
in like manner circumscribed or diffused to a greater or less extent 
over the affected side. 

Even if the presence of a foreign body somewhere in the air- 
passages be not known, the combination of physical signs just 
mentioned is almost proof positive of its existence, provided it be 
ascertained that they have been suddenly developed. As remarked 
by Stokes, there are but three affections capable of producing a 
similar assemblage of signs, viz., pressure on a bronchus by an aneu- 
rism or some other tumor : obstruction of the tube by hypertrophy 
of the mucous membrane, and its occlusion by an accumulation of 
viscid mucus. The symptoms and the previous history will rarely, 
if ever, leave much room for doubt, when it is a problem of diagnosis 
to decide between the presence of a foreign body in the bronchus, 
or the existence of one of these three morbid conditions. 

Evidence still more demonstrative of the presence of a foreign 
body is afforded when it is found to shift its place, being removed 
from its situation in the bronchus by an act of coughing, and carried 
upward into the trachea, or perhaps transferred to the bronchial tube 
on the opposite side. Its dislodgment from the bronchus is imme- 
diately followed by the reappearance or the normal development of 
the vesicular murmur on the side where it had been found to be 

' Vide Gross on Foreign Bodies, p. 107. 



FOREIGN BODIES IN THE AIR-PASSAGES. 625 

abnormally feeble or suppressed. If the body be easily displaced, 
and hence thrown upward from time to time, the physical evidence 
of obstruction of the bronchus will be intermittent ; and if the body 
occasionally be transferred to the other bronchus, as has been repeat- 
edly observed, the two sides will be found to present the character- 
istic combination of signs in alternation. Under these circumstances 
nothing could be added to render the diagnostic proof more positive. 
On this point Dr. Stokes remarks : " There is not in the whole range 
of stethoscopy more striking phenomena than the sudden rush of 
air into the lung, on the foreign body passing into the windpipe, or 
the equally sudden disappearance of all sound of expansion, natural 
and morbid, when the bronchus becomes again obstructed." The 
effect is, of course, more striking when the foreign body produces 
sufficient closure of the tube to arrest all respiratory sound, but the 
evidence is equally clear when there is obstruction enough to cause 
a notable diminution in intensity of the vesicular murmur. 

It is obvious on comparing the phenomena furnished by an exami- 
nation of the chest in cases in which the foreign body is seated in 
' the larynx or trachea, with those which indicate its situation to be 
in the bronchus, that the diagnostic evidence in the latter is more 
striking and positive. In connection with this fact it is to be borne 
in mind that of a given number of cases, in vastly the larger propor- 
tion the foreign body falls into the right bronchus. 

In the diagnosis of foreign bodies in the air-passages, not only are 
the physical signs to be associated with the symptoms, but in many 
if not most instances, as regards their relative rank, they are subor- 
dinate to the latter. In treating of this subject, however, as of the 
diseases affecting the trachea and larynx, my purpose was to con- 
sider it only in its relations to the principles and practice of physical 
exploration. 



SUMMARY OF THE PHYSICAL SIGNS OF FOREIGN BODIES IN THE 
AIR-PAS SAGES. 

A sibilant or sonorous rale, either limited to the larynx, trachea, or 
bronchus, or having its maximum of intensity over one of these 
portions of the air-passages, and in some instances changing its 
place from one portion to another. After a time a mucous rale in 
either of the same situations ; occasionally a valvular or flapping 

40 



626 DISEASES OF THE EESPIRATORY ORGA^'S. 

sound. Motion of the foreign body sometimes perceived during acts 
of coughing by palpation. 

Feebleness or suppression of the vesicular murmur equally on both 
sides, if the foreign body be situated -within the larynx or trachea ; 
the percussion-resonance remaining clear. If the foreign body be 
situated in a bronchus, the vesicular murmur on the corresponding 
side enfeebled or suspended, the percussion-resonance remaining 
clear, except collapse of the lung be induced. Feebleness or sup- 
pression of the murmur sometimes suddenly giving place to a well- 
evolved and normal respiratory sound, after an act of coughing, 
which dislodges the foreign body, and carries it upward into the 
trachea. Occasionally feebleness or suppression of the vesicular 
murmur transferred from one side to the other, indicating a removal 
of the foreign body from the bronchus of one side to that of the 
other side. Exaggerated vesicular respiration on the side opposite 
to that on which the murmur is found to be diminished or suppressed. 
Dry and moist bronchial rales, after a time, more or less diifused over 
the side corresponding to the bronchus in which the foreign body is 
lodged. 



APPENDIX. 

ON THE PITCH OF THE WHISPEEING SOUFFLE OVER 
PULMONARY EXCAVATIONS. 

In the foregoing pages, I have repeatedly referred to the souffle 
accompanying the act of whispering, as a sign of pulmonary con- 
densation, especially from inflammatory, tuberculous, or other soli- 
difying deposit. Since the chapter on Tuberculosis was written, 
my attention has been directed to the whispering souffle over exca- 
vations in that affection. In several instances I have found within 
a circumscribed space where other cavernous signs were present, a 
souffle more or less intense and loiv in pitchy contrasting in this 
particular strongly with the normal bronchial souffle, as well as 
with that significant of solidification, the latter being heard around 
the circumscribed space. For example, in a case at this moment 
under observation, the cavernous respiration exists at the summit 
of the chest on both sides. Surrounding the site of the cavity on 
either side the whispering souffle is acute or high, and within the 
area to which the cavernous respiration is limited (a space not 
more than an inch in diameter), the souffle becomes abruptly and 
notably low in pitch — the contrast, in fact, being more marked 
than between the cavernous and the surrounding bronchial respira- 
tion. A low-pitched cavernous souffle would be rationally antici- 
pated ; for the sound, as has been more than once remarked, is none 
other than that incident to a forcible expiration ; and the expiration 
being low in the cavernous as contrasted with the bronchial respira- 
tion, it might be presumed that a similar disparity would be appa- 
rent in the act of whispering. This process of reasoning, however, 
never occurred to me till the disparity had been noticed. If the 
fact of this disparity be found to hold good after repeated observa- 
tions, a new and an important cavernous sign is acquired, viz., a 
low-pitched whispering souffle. It is not, however, to be expected 



k 



628 APPEAL IX. 

that this siflTi will always be ayailable when cavitie? eri^r. F r :L- 
same reason that the bronchial respiration may Lt ii: ::t 1 
mask the cayernons, the bronchial sonffle may conTii r : t t . :. 
notwithstanding the existence of an excavation. Ii is ax^c- pio;:?. .r 
that, as the bronchial and cay ernous respiration are sometimes cm- 
mingled, forming what I haye called the broncho-cavemous respira- 
tion, so the bronchial and cayernons sonffle maj be combined in 
different cases in yarying proportions. 

I have felt the need of a term to designate the sonffle incddent 
to solidification. Whispering hroncTwpJiony would be appropriate, 
especially as we haye already the term whispering pectoriloqny. 
Adopting this title, and limiting it to the acnte souffle emanating 
from the bronchial tubes and constituting the sign of solidification, 
another is wanted to distinguish the sonnd produced in an excava- 
tion. I can suggest no better term expressive of the latter than 
cavernous wliisper. This simple name accords with the term 
cavernous respiration. Whispering pectoriloqny, according to my 
experience, is by no means reliable as a sign of excavation. I 
have observed it repeatedly over solidified lung. But from the 
results just given, it may be inferred that the pitch of the vocal 
sound accompanying the transmitted speech, wlQ furnish a test to 
determine whether the pectoriloquy be or be not cavernous in its 
source. 



INDEX. 



Abdominal respiration, 

Absence of percussion-resonance [vide 

Flatness), . ... 99 
Acoustics, importance of, in study of 

physical exploration. 
Adventitious respiratory sounds (vide 

Rales), 

-(Egony, 

iEgophony, 

mechanism of, . 

in pneumonitis, 

in pleuritis, 
Air-cells, description of, 
Amphoric voice, . 

percussion -resonance, 



24 



108 



66 



216 

. 273 

. 267 

. 274 

. 419 
553, 566, 568 

. 41 

. 263 

. 119 

respiration, 208 

in pulmonary tuberculosis, . 482 

in pleuritis, . . . 547, 549 

in pneumo-hydrothorax, . 592 

Apoplexy, pulmonary, . . . 521 

physical signs of, .... 522 

diagnosis of, .... 522 

summary of physical signs of, . 524 

Aran, Dr., observations on tympanitic 

percussion-resonance in pleuritis, . 115 

Asthma, 397 

physical signs of, . . . . 397 
diagnosis of, .... 398 
summary of physical signs,. . 400 
Atelectasis, . . . . . 432 
physical signs and diagnosis of, . 435 
Attrition-sounds, (vide Friction- 
sounds) 242 

Auscultation, definition of, . 66, 126 

mediate and immediate, . . 126 
rules for performing, . . 131,133 

phenomena furnished by, . . 134 

in health, 136 

in disease, 175 

history of, 292 

signs correlative to, . . . 342 

in bronchitis, . 354, 363, 371, 373 

in bronchial catarrh, . . . 37H 

in dilatation of bronchia, . . 384 

in contraction of bronchia, . . 394 

in pertussis, .... 396 

in asthma, 397 

in pneumonitis, .... 408 

in pulmonary tuberculosis, . . 469 

in oedema, 513 



Auscultation in gangrene, . . . 517 

in pulmonary apoplexy, . . 522 
in cancer of the lungs, . 526, 533 

in atelectasis, .... 435 

in collapse, 436 

in lobular pneumonitis, . . 437 

in chronic pneumonitis, . . 441 

in vesicular emphysema, . . 445 

in interlobular emphysema, . 457 

in acute pleuritis, . . . 545 

in chronic pleuritis, . . 565, 568 

in pneumo-hydrothorax, . . 592 

in diaphragmatic hernia, . . 605 
in diseases affecting the trachea 

and larynx, ... . . 610 

Autophonia, ..... 275 

Axillary region, 61 

percussion-resonance in, . . 92 

respiratory phenomena in, . , 162 

vocal resonance in, . . . 173 



B. 



Barth, M., on exploration of trachea 

and larynx, ..... 610 
Barth and Roger on bronchial respira- 
tion in pleuritis, .... 547 
Beau and Maissiat's division of types 

of breathing, ..... 25 

Bellows arterial sound, . . . 291 

in pulmonary tuberculosis, . . 479 

in cancer, 533 

of heart, in pleuritis, . . . 557 
Bennett, Dr. J. Hughes, on cirrhosis 
of lungs, . . . . . .383 

Blowing respiration {vide Bronchial 

Respiration, 187 

Borboiygmi in diaphragmatic hernia, 607 

Bowditch, Dr. H. I., on tuberculosis, 501 

on diaphragmatic hernia, . . 603 

Bronchi, description of, . . . 47 

Bronchia, description of, . . 37, 40 

dilatation of, .... 380 

physical signs of, . . . . 383 

diagnosis of, .... 385 

summary of the more important 

of the diagnostic characters of, 391 

contraction of, ... . 391 

Bronchial catarrh, .... 378 

cough, 279 



630 



INDEX. 



Bronchial septum, 

respiration, normal, 
abnormal, 
in dilatation of bronchi? 



48 
140 
187 
384 

in pneumonitis, . . . 412 
in pulmonary tuberculosis, . 477 
in oedema, .... 513 
in cancer, . . . 526, 533 
in gangrene, .... 517 
in pulmonary apoplexy, . 522 

in atelectasis, . . . 435 

in collapse, .... 436 
in lobular pneumonitis, . 438 

in chronic pneumonitis, . 441 

in acute pleuritis, . . . 546 
in pneumo-hydrothorax, . 593 

Bronchial rales, 218 

in bronchitis, . . . 354, 371 
in dilatation of bronchia, . . 384 
in pneumonitis, .... 411 
signs correlative to, . . . 344 
in pulmonary tuberculosis, , 474,478 

in oedema 513 

in gangrene,. .... 517 

in pulmonary apoplexy, . . 522 

in cancer, .... 526, 533 

in emphysema, .... 447 

in pleuritis, .... 549,5fi5 

Bronchial phthisis, .... 509 

Bronchiectasis, ..... 380 

Bronchioles, description of, . .40 

Bronchitis, 352 

divisions of, 353 

acute, 353 

physical signs of, . . . . 353 

diagnosis of, 357 

summary of physical signs of, . 362 

capillary, 362 

physical signs and diagnosis of, 362 
summary of physical signs of, 369 
pseudo-membranous or plastic, . 369 
physical signs and diagnosis of, 371 
summary of physical signs of, 372 

chronic, 373 

physical signs of, . . . 373 
diagnosis of, . . . . 375 
summary of physical signs of, 377 

secondary, " 377 

Broncho-cavernous respiration, . . 482 

Broncho-vesicular respiration, . . 197 

in pneumonitis, .... 414 

signs correlative to, . . . 345 

in pulmonary tuberculosis, . . 469 

in oedema, 513 

in pulmonary apoplexy, . . 522 
in atelectasis, .... 435 

in collapse, 436 

in lobular pneumonitis, . . 438 
in acute pleuritis, .... 545 

Bronchophony, 251 

mechanism of, . . . . 257 
in dilatation of bronchia, . . 384 
in pneumonitis, .... 416 
in pulmonary tuberculosis, . . 480 
in pulmonary apoplexy, . . 522 
in gangrene, .... 517 

in cancer, 526 

in pleuritis, .... 552, 566 
in pneum.o-hydrothorax, . . 593 



Bruit de pot fell {vide Cracked-metal 

sound), 119 

Bruit de soupape in plastic bronchitis, 371 
in pedunculated tumor within tra- 
chea, 613 



C. 

Callipers, 312 

Cammann's stethoscope, . . 130,485 

Cancer of the lungs, .... 524 

in mediastinum, .... 531 

physical signs of, . . . . 532 

diagnosis of, .... 534 

Capillary bronchial tubes, . . 40 

Carnification, 433 

Carr, Dr. E. A., explanation of crepi- 
tant rale, 234 

Catarrh, bronchial, .... 378 

Cavernous cough, .... 280 

whisper (Appendix), . . . 627 

Cavernous rale, 235 

in pneumonitis, .... 425 

Cavernous respiration, . . . 202 

signs correlative to, . . . 345 

in dilatation of bronchia, . . 385 

in pneumonitis, .... 425 

in pulmonary tuberculosis, . . 481 

in gangrene, .... 518 

in pleuritis, 547 

in pneumo-hydrothorax, . 592, 593 

Cavernous voice, .... 263 

in pneumonitis (vide Pectoriloquy), 425 

Chest, exploration of, in health, . 71 

size of, in health, ... 33 

topographical divisions of, . . 54 
morbid appearances pertaining to 

size and form, .... 297 
in pneumonitis, .... 420 
in dilatation of bronchia, . . 381 
variations of size in various dis- 
eases, 316 

in cancer, .... 526, 533 
in emphysema, .... 449 
in pleuritis, . . 554,566,567 
in pneumo-hydrothorax, . . 594 
in diaphragmatic hernia, . . 606 
exploration of, in diseases of tra- 
chea and larynx, . . 614 
in foreign bodies in air-passages, 622 
Chest-measurer, . . .29, 317 
Chordne-vocales, .... 51 
Cirrhosis of lungs, .... 381 
Clavicular region, .... 56 
percussion-resonance in, . . 81 
Cogged- v.heel respiration (vi^Ze Inter- 
rupted Respiration), . . . 215 
Collapse of lung, . . . . 433 
physical signs and diagnosis of, , 435 
Consonance, theory of, . . . 192 
Contraction of chest {vide Chest). 
Corrigan, Dr., on cirrhosis of lungs, . 381 
Costal respiration, ... .23 
cartilages, description of . . 18 
Costo-pulmonary pleuritis, . . 582 
Cough, phenomena incident to, in 

health 174 

in disease, 279 



INDEX. 



631 



Cough, bronchial, 

cavernous, . 
Cracked-metal percussion-sound, 

in tuberculosis, . 

in pleuritis, . 
Crackling, .... 

in pulmonary tuberculosis, 
Crepitant rale, . 

in pneumonitis, . 

in pulmonary tuberculosis, 

in oedema, . . . 

in pulmonary apoplexy, 

in atelectasis and collapse, 

in lobular pneumonitis, 

in gangrene. 
Crepitant rale redux, 

in pneumonitis, . 
Cri sonore in disease of larynx. 
Crumpling, pulmonary, 

in pulmonary tuberculosis. 



D. 



228. 



279 
280 
120 
466 
545 
239 
473 
228 
409 
473 
513 
522 
436 
437 
518 
233 
410 
611 
238 
473 



DaUon, Prof. John C, experiments on 




the respiratory movements of the 




glottis, .... 


. 


52 


Deferred inspiration, . 


. 


210 


in emphysema. 
Diagnosis of diseases of respii 




446 


atory 




organs, general remarks on. 


351 


Diaphragm, 




20 


displacement of, in pleuritis 


, 558 


567 


Diaphragmatic hernia. 




602 


physical signs of. 




604 


diagnosis of, 




606 


Diaphragmatic breathing, . 




24 


pleuritis. 




582 


Dilatation of bronchial tubes. 




380 


of chest {vide Chest). 






Diminished intensity of vesicular mur- 




mur, .... 


. 


180 


in bronchitis. 


. 


356 


in asthma, . 


. 


397 


signs correlative to, 


, 


342 


in pneumonitis, . 




408 


in oedema, . 


. 


514 


in cancer, 


. 


525 


in atelectasis, 


, 


435 


in emphysema, . 




445 


in acute pleuritis. 




545 


Diminished vesicular resonance 


{vide 




Dulness), . 




99 


Diminished vocal resonance. 


250 


,261 


Dryness of respiratory sound, . 




188 


Duhiess of percussion-sound. 


99 


, 102 


in dilatation of bronchia. 


. 


383 


in pertussis, . 


. 


395 


in bronchitis. 


. 


353 


in pneumonitis, . 


. 


404 


in pulmonary apoplexy, 




522 


in oedema, . 


. 


513 


in gangrene. 




517 


in cancer, 


. 525 


532 


in atelectasis, 


, 


435 


in collapse, . 


. 


436 


in lobular pneumonitis. 


, 


438 


in chronic pneumonitis, 




441 


in pleuritis, . 


. 


540 



E. 

Echo, metallic, . 
Emphysema, 

vesicular, 

physical signs of, 

diagnosis of, 

summary of physical signs of, 

interlobular. 
Empyema, . 

pulsating, 

multilocular and unilocular. 
Enlargement of chest {vide Chest), 
Exaggerated respiration, . 

in pneumonitis, 

signs correlative to, . 

in cancer, .... 

in tuberculosis, . 

in lobular pneumonitis, 

in pleuritis, .... 

in pneumo-hydrothorax, 
Exaggerated vesicular resonance, 
99, 

in pneumonitis, . 
Exaggerated vocal resonance, 

in pulmonary tuberculosis, 
apoplexy, 

in oedema, . 

in gangrene, 

in cancer, 

in vesicular emphysema, 

in interlobular do., . 

in pleuritis, . 
Expiration, 

prolonged, . 



324 



472, 
549, 



100, 
416, 
251, 



208 
443 
443 
444 
452 
455 
455 
578 
581 
582 

177 
416 
342 

526 
478 
438 
566 
593 

177 

408 
249 
475 
522 
514 
517 
525 
444 
437 
566 
31 
211 



Feeble respiration {vide Diminished 
Vesicular Murmur), . . . 180 

Flatness, on percussion, ... 99 

in pneumonitis 404 

in cancer, .... 525, 532 
in pleuritis, .... 542, 565 
in pneumo-hydrothorax, . . 590 

Fluctuation in cancer, . . . 533 
in pleuritis, .... 559, 567 

Foreign bodies in the air-passages, . 618 

exploration of trachea and larynx, 620 

of chest, .... 622 

summary of physical signs, . . 625 

Fournet, on exaggerated respiration, 178 
on pneumonitis, .... 408 

Fremitus, vocal {videYoca.\ Fremitus), 326 
tactile, in pleuritis, . . . 568 

Friction-sounds, pleural, . . . 242 
signs correlative to, . . . 347 
in pneumonitis, . . . .412 
in pulmonary tuberculosis, . . 478 
in pleuritis, .... 550, 568 



G. 



Gangrene of lungs, .... 515 

physical signs of, . . . . 516 

diagnosis of, .... 518 

summary of physical signs of, . 520 



632 



INDEX. 



Glottis, 51 

respiratory movements of, . . 52 

Graves' observations on tympanitic 

resonance in pneumonitis, . . 115 

Gross on foreign bodies in air-pas- 
sages, 49,619 

Gurgling, . . . .. .219, 235 

in dilatation of bronchia, . . 385 

in pulmonary tuberculosis, . . 483 

in gangrene, .... 518 

in diaphragmatic hernia, . . 605 



H. 



Hardness of respiratory sound, . .188 
Haemoptoic infarctus, . . . . 521 
Heart, abnormal transmission of 

sounds of 289 

in pleuritis, .... 546 
in pulmonary tuberculosis, 475, 479 
in cancer, .... 526 
dislocation of, in cancer, . . • 533 
in pleuritis, .... 557, 566 
in pneumo-hydrothorax, . . 594 
in diaphragmatic hernia, . . 606 
Hepatic flatness, line of, . . . 87 
Honore, discoverer of friction-sounds, 248 
Hooping-cough, . ... . 395 
physical signs and diagnosis of, . 395 
Hutchinson on vital capacity of lungs, 44 
Hydroihorax, ..... 586 
Hypervesicular respiration {vide Ex- 
aggerated Respiration, . . . 177 



Increased intensity of respiratory 
sound (vide Exaggerated Respira 
tion), .... 
Indeterminate rales, . 
Infra-axillary region, . 

percussion-resonance in, 

respiratory phenomena in 

vocal resonance in, 
Infra-clavicular region, 

percussion-resonance in, 

comparison of respiratory sound 
in health on the two sides, 

vocal resonance in. 
Infra-mammary region, 

percussion-resonance in, 

respiratory phenomena in 

vocal resonance in, 
Infra-scapular region, 

percussion-resonance in, 

respiratory phenomena in 

vocal resonance in, 
Inspection, .... 

in health, 

in disease, . 

summary of signs pertaining to 

history of, . 

in dilatation of bronchia, 

in pneumonitis, . 

in pulmonary tuberculosis, 

in cancer, 

in cedema, . 

in atelectasis. 



177 

219, 237 

61 

92 

162 

173 

56 

81 



155 

171 

59 

87 

160 

173 

60 

91 

160 

172 

295 

296 

297 

308 

311 

384 

419 

485 

526, 533 

514 

435 



66, 



Inspection in emphysema, . 




447 


in pleurhis, .... 


554 


566 


in pneumo-hydrothorax. 




594 


Inspiration, .... 


. 


31 


shortened, .... 




210 


in emphysema, . 




446 


Insufflation in atelectasis and collapse. 


433 


Intercellular passages, 




40 


Intercostal spaces. 


'l9, 26 


in pneumonitis, . 




420 


in cancer, .... 


526 


533 


in emphysema, . 


450 


451 


in pleuritis, .... 


554 


555 


in pneumo-hydrothorax, 




594 


Intercostal neuralgia, diagnosis of, . 


597 


Interlobar fissure, 




36 


mode of delineating on chest 


by 




percussion. 




109 


in pneumonitis. 




407 


by auscultation. 


415 


418 


pleuritis, .... 




585 


Interlobular septa. 




39 


Interrupted or jerking respiration. 




214 


in pulmonary tuberculosis, . 




472 


in pleuritis, .... 




545 


Inter-scapular region. 


. 


60 


percussion-resonance in, 




91 



J. 

Jackson, Dr. James, Jr., on prolonged 
expiration, 



L. 



Laryngophony, 

Larynx, description of, . . . 
superior aperture of, . 

inferior space 

diseases of, . 
Lavvson on friction-sound produced by 
miliary tubercles, .... 
Liquid, in pleural cavity, mode of de- 
tecting by percussion, 
Lobes, description of, ... 

Lobular pneumonitis (vide Pneumo- 
nitis). 
Lobules, description of, . 



M. 



Mammary region, .... 

percussion-resonance in, 

respiratory phenomena in, . 

vocal resonance in, . . . 
Measurement of the chest in health. 
Mediastinum, displacement of, in 

pleuritis, .... 544, 545, 
Mensuration, . ... 66, 

summary of facts pertaining to, . 

in pneumonitis, .... 

in pulmonary tuberculosis, . 

in emphysema, .... 

in cancer, 

in pleuritis, .... 554, 

in pneumo-hydrothorax. 
Metallic respiration, .... 



211 



164 
49 
50 
53 

609 

247 

110 
36 



38 



57 

84 

160 

173 

21 

567 
312 
320 
420 
486 
451 
534 
566 
594 
188 



INDEX. 



633 



Metallic tinkling, 




282 


Percussion in oedema, 


513 


summary of facts pertaining 


to, . 


289 


in pneumonitis, .... 


404 


in dilatation of bronchia, 




385 


in pertussis, 


395 


in pulmonary tuberculosis, . 




483 


in pulmonary tuberculosis, . 


461 


in pneumo-hydrothorax, 




593 


in gangrene, .... 


517 


in diaphragmatic hernia, 




605 


in pulmonary apoplexy, 


522 


Monneret and Barthez on cavernous 




in cancer of the lungs, 


525 


respiration in pleuritis, . 




547 


in cancer of the mediastinum, 


532 


Mucous rales, .... 




223 


in atelectasis, .... 


435 


in pulmonary tuberculosis, . 




474 


in collapse, ..... 


436 


in cancer, .... 




526 


in lobular pneumonitis. 


438 


in pulmonary apoplexy. 




522 


in vesicular emphysema. 


444 


in diseases of larynx and trachea, 


614 


in interlobular emphysema, . 


457 


in foreign bodies in the air- 


pas- 




in acute pleuritis, 


540 


sages, . . 




622 


in chronic pleuritis, . . 565 
in retrospective diagnosis of, 
in pneumo-hydrothorax, 


, 568 
577 
590 


. N. 






in diaphragmatic hernia, 

in diseases of the trachea and 


605 


Neuralgia, intercostal, 


. 


597 


larynx, 


609 


Nipple, elevation of, in pleuritis, 


• 


566 


in foreign bodies in air-passages, 

Percussors, 

Pertussis, 


620 

76 

395 


0. 






Phthisis, acute (vide Tuberculosis, 
Acute), 


503 


CEdema of lungs (vide Pulmonary 




Physical diagnosis, definition of. 


66 


CEdema). 






Physical exploration, definition of, . 


65 


Oval fossa of larynx, . 


• 


50 


methods of, 

advantages of, ... . 
different aspects of, . . 


65 
68 
71 


P. 






mode of studying, 

in diseases aflecting the trachea 


73 


Palpation, 


66 


323 


and larynx, .... 


609 


summary of facts, 




329 


in foreign bodies in the air-pas- 




history of, . 


. 


329 


sages, 


618 


in pneumonitis, 


. 


420 


Physical signs, definition of, . 66, 71 


in pulmonary tuberculosis, . 




487 


recapitulatory enumeration of, . 


333 


in cancer, .... 


526 


,533 


correlation of, ... . 


336 


in emphysema, 




451 


Piorry's " water sound," . 


120 


in pleuritis, .... 


556 


566 


Pitch of percussion-sound, . 


108 


in pneumo-hydrothorax, 




594 


in bronchial respiration, 


188 


in foreign bodies in air-passages, 


621 


in broncho-vesicular or rude respi- 




Pectoriloquy, .... 


165 


263 


ration, 


198 


whispering, .... 




266 


in cavernous respiration, 


203 


mechanism of, . 




266 


in prolonged expiration, 


214 


in dilatation of bronchia, 




385 


in cavernous whisper {Appendix), 


627 


in pulmonary tuberculosis, . 




483 


Pleura . 


34 


in gangrene, 




518 


Pleuralgia, 


597 


in cancer, .... 




533 


Pleuritis, acute, 


538 


in pleuritis, .... 




552 


physical signs of, . 


540 


in pneumo-hydrothorax, 




593 


diagnosis of, .... 


559 


Pennock's flexible stethoscope^ 




129 


summary of physical signs of. 


562 


Percussion, .... 


65,75 


chronic, 


564 


immediate, .... 




75 


physical signs of, . 


565 


mediate, .... 




75 


diagnosis of, .... 


568 


mode of performing, . 




77 


retrospective diagnosis of, . 


572 


auscultatory, 


78, 91 


summary of characters. 


577 


in health, .... 




78 


circumscribed, .... 


582 


rules of performing, 




94 


Pleurodynia (vide Pleuralgia), . 


597 


in praecordia, 




85 


Pleximeters, 


75 


in disease, .... 




98 


Pneumonitis, acute lobar, . 


401 


deep and superficial, . 




86 


typhoid, 


402 


summary of facts, 




122 


catarrhal, 


402 


history of, . 




124 


traumatic, 


402 


signs correlative to. 




338 


bilious, 


402 


sense of resistance in, . 




97 


latent, 


402 


in bronchitis, . 353, 36c 


1, 371 


, 373 


double, 


402 


in dilatation of bronchia. 




383 


stages of, 


403 


in contraction of bronchia, . 




394 


physical signs of, . 


404 


in asthma, .... 




397 


diagnosis of, 


421 



41 



634 



INDEX. 



Pneumonitis, summary of physical 

signs of, 431 

lobular, 432 

physical signs and diagnosis of, . 435 

chronic, 440 

Pneumorrhagia (vide Pulmonary Apo- 
plexy), 521 

Pneurao-thorax pneumo-hydrothorax, 587 

physical signs of, . . . . 590 

diagnosis of, 595 

summary of physical signs of, . 596 

Post-clavicular region, ... 56 

percussion-resonance in, . . 80 

respiratory phenomena in, . . 155 

Praecordia, clearness of percussion- 
sound in, in emphysema, . . 4-45 

Prolonged expiration, . . . 211 

Puerile respiration {vide Exaggerated 

Respiration), 177 

Pulmonary oedema, .... 512 

physical signs of, . . . . 513 

diagnosis of 514 

summary of physical signs, . . 515 

organs, description of, . . 34 
tuberculosis {vide Tuberculosis). 



Quain's stethometer, 



30, 318 



216 



Rales, definition of, . ■. . . 
table showing number, names, and 
anatomical situations of, . 

tracheal, 

sonorous, 

sibilant, 

mucous, 

sub-crepitant, .... 
cavernous or gurgling, 
indeterminate, .... 
dry crepitant with large bubbles, 
crumpling, . . . • . 

crackling. 

table exhibiting distinctive cha- 
racters and diagnostic indica- 
tions of, .... . 
signs correlative to, . 
enumeration of, in cases of foreign 
bodies in air-passages. 
Rattles {vide Rales). 

Regions, 55 

anterior, . . . . 55, 56 
posterior, . . . . 55, 60 

lateral, 55, 61 

Resistance on percussion {vide Sense 
of Resistance), .- 

Resonance on percussion, vesicular, 
tympanitic {vide Tympanitic Re 

sonance), .... 
signs correlative to, 
comparison in different regions, 
exaggerated vesicular, 

signs correlative to. 
diminished vesicular, . 
signs correlative to, 
absence of, . 

signs correlative to. 



79 

111 
341 

80 
100 
338 
102 
339 
108 
340 



219 
217 
221 
220 
223 
226 
235 
237 
237 
238 
239 



240 
346 



621 



Resonance, gastric tympanitic, . 
! tubular, .... 

i liver, spleen, and heart, 
j amphoric, .... 

I cracked-metal, 

j Respiration, types of, . 
I phenomena of, in health, 
i tracheal, .... 
normal bronchial, 
vesicular, .... 
{ comparison of tracheo-bronchial 

and vesicular, 
I in right and left infra-clavicu 

lar regions, 
in right and left upper scapu 

lar regions, 
in right and left lower scapu 

lar regions, 
in right and left infra-scapular 
regions, .... 
in axillary and infra-axillary 

regions, .... 
in mammary region, 
phenomena incident to, in disease 
abnormal modifications of, . 
exaggerated, 

signs correlative to, 
feeble or weak, 

signs correlative to, 

suppressed 

signs correlative to, 
bronchial, .... 

signs correlative to, 
broncho-vesicular, 

signs correlative to, 

cavernous 

signs correlative to, 
amphoric, .... 
tabular view of abnormal modifi 

cations of, . 
interrupted, jerking, and wavy, 
frequency of, in health, 
Respiratory apparatus, components of, 
sounds, adventitious {vide Rales) 
Respiratory movements, . 22, 29, 30 
in the female, 
influence of age on, 
in cancer, . 
in pneumonitis, 
in atelectasis 
in tuberculosis, 
in emphysema, . . . 448 
in pleuritis, . . . 554, 566. 
in pneumo-hydrothorax, 
in diaphragmatic hernia, 
Rhonchal fremitus, .... 
Rhonchi [vide Rales). 
Ribs, direction of, etc., 

divergence and convergence in 

pleuritis, 

Roger, Dr. Henri, on tympanitic per- 
cussion-resonance in pleuritis, 114, 
Rude respiration, . . . 197, 
in emphysema, .... 



S. 



Scapular regions, 

percussion-resonance in, 



89 

89 

90 

119 

120 

25 

137 

137 

140 

146 

149 

155 

156 

158 

160 

162 
162 
175 
176 
177 
342 
180 
343 
185 
343 
187 
344 
197 
345 
202 
345 
208 

209 
214 
305 
17 
216 
304 
26 
28 
526 
419 
435 
436 
450 
567 
594 
606 
328 

18 

566 

544 
470 
446 



60 

83 



INDEX. 



635 



Scapular regions, respiratory pheno- 
mena in, . . . . 156, 158 
vocal resonance in, . . . 172 
Sense of resistance in percussion, . 97 
in emphysema, .... 445 
in cancer, ..... 532 
in pleurisy, .... 543, 565 
in pneumo-hydrothorax, . . 591 
in supra-clavicular region, . . 55 
Shortened inspiration, . . . 210 

Sibilant rales, 220 

in bronchitis, . . . 354, 371 

in asthma, 397 

in pneumonitis, .... 412 
in capillary bronchitis, , . 363 

in emphysema, .... 447 
in diseases of trachea and larynx, 611 
in foreign bodies in air-passages, 621 
Sibson's chest-measurer, . . 28,318 

Signs, physical, 66 

Skoda, his views of percussion-sound 
over solid viscera, 
division of percussion-sounds into 

empty and full, 
on tympanitic resonance in pleu- 
risy, 114 

explanation of, 
theory of consonance, , 
on bronchophony, 
on tympanitic percussion 
nance in oedema, 
Sonorous rales, . 
in bronchitis, 
in asthma, . 
in pneumonitis, . 
in emphysema, 

in diseases of trachea and larynx 
in foreign bodies in air-passages 



90 

100 

540 

. 117 

. 192 

252, 256 

reso- 

. 513 
. 221 
354, 371 
. 397 
. 412 
. 447 
611 
621 



pro 



Souffle, with whispered words, vide 
Whispering Souffle ; arterial, vide 
Bellows Arterial Souffle. 
Spine, curvature of, in pleuritis 

in emphysema, 
Spirometer, 
Splashing, .... 

in pulmonary tuberculosis, 

in pneumo-hydrothorax, 
Sternal regions, . 

percussion-resonance in, 
Stethometer, 
Stethoscope, 

different kinds of, 
Stokes on pleural friction-sound 
duced by heart, 

on exploration of larynx and tra 
chea, 
Sub-crepitant rale, 

in capillary bronchitis, 

in pulmonary tuberculosis, 

in oedema, . 

in pulmonary gangrene, 
Succussion, 

summary of facts, 

history of, . 

in pneumo-hydrothorax, 

in pulmonary tuberculosis, 
Supplementary respiration {vide Exag 

geraied Respiration), 
Suppressed respiration, 

in bronchitis, . . . 356. 



555 

449 

44, 319 

330 

488 
594 
59 
89 
318 
126 
128 



244 



610 
226 
363 
474 
513 
517 
e&, 330 
332 
332 
594 
488 

177 
185 
371 



Suppressed respiration, signs correla 
tive to, . 

in pulmonary tuberculosis 

in oedema, 

in cancer, 

in atelectasis, 

in emphysema, 

in acute pleuritis, 

in chronic pleuritis, 

in pneumo-hydrothorax 
Suppressed vocal resonance, . 250 
Suprasternal region, . 
Swett, Prof., on cancer, 
Symmetry, deviations from 
Symptoms, definition of, . 



343 

476 

514 

525 

435 

446 

546 

565 

593 

261 

59 

533 

21 

66 



T. 

Tape for measuring chest, . 
Thomson on prolonged expiration, . 

on interrupted respiration, . 
Thoracic parietes, description of, 

breathing, 

Topographical divisions of chest, 
Trachea, 

diseases affecting, 
Tracheal respiration, .... 

voice, ...... 

souffle, 

rales, 

Tracheophony, 

Tremhloiement in croup, 
Tuberculosis pulmonary, . 

stages of, 

physical signs of, ... 

diagnosis of, .... 

summary of physical signs belong- 
ing to, 

acute, 

retrospective diagnosis of, . 

bronchial, 

Tubular respiration, .... 
Tympanitic percussion-resonance, 99, 

in pleuritis, . . . 114, 540, 

in pneumonitis, . . . 115, 

in dilatation of the bronchia, 

in asthma, . 

in pulmonary tuberculosis, 

in oedema, . 

in cancer, 

in vesicular emphysema, 

in interlobular emphysema 

in pneumo-hydrothorax, 

in diaphragmatic hernia, 
Types of breathing, . 



464, 



526, 



25, 



U. 

Unfinished inspiration. 



314 

213 

216 

17 

23 

54 

46 

609 

137 

164 

166 

613 

164 

612 

458 

460 

461 

488 

502 
503 
506 
509 
187 
111 
544 
405 
384 
397 
466 
513 
532 
444 
457 
590 
605 
307 



211 



Valvular sound in larynx and trachea, 

in cases of foreign bodies, . 622 

Vesicular murmur, increased intensity 
of {vide Exaggerated Respira- 
tion), 177 



636 



INDEX. 



Vesicular murmur, diminished inten- 
sity of ivide Diminished Intensity 
of Respiratory Sound and Respira- 
tion), 

Vesicular respiration. 
Vital capacity of lungs, . . 
Vocal fremitus, . . . 
in dilatation of bronchia, 
in pneumonitis, . . . . 
in pulmonary tuberculosis, . 
in CEdema, ..... 
in pulmonary apoplexy, 
in cancer, 

in lobular pneumonitis, 
in chronic pneumonitis, 
in pleuritis, ... 
Vocal resonance, normal vesicular, 
comparison of right and left infra- 
clavicular regions, . 
of scapular regions, 
of infra-scapular regions, 
of mammary and infra-mammary 

regions, 

of axillary and infra-axillary re- 
gions, 

brief summary of facts, 
exaggerated vocal resonance and 
bronchophony, .... 
diminished and suppressed reso- 
nance, . . . . . 
in pulmonary tuberculosis, , 

in oedema, 

in pulmonary apoplexy, 

in collapse, 

in lobular pneumonitis, 
in chronic pneumonitis, 
in emphysema, .... 



180 

146 

44 

326 

384 

420 

487 

514 

522 

526, 53*3, 534 

. 438 

. 441 

557, 567, 568 

168 

171 
172 

172 

173 

173 
173 

251 

261 
479 
514 
522 
436 
438 
441 
447 



Vocal resonance, in cancer, . 526, 533 
in pleuritis, . . . 552, 566, 568 
in pneumo-hydrothorax, . . 593 
Vocal signs, summary of facts pertain- 
ing to, 275 

Voice, phenomena of, incident to 

health, 163 

tracheal, 164 

phenomena of, incident to disease, 249 
classification of morbid pheno- 
mena, 249 

whispering souffle, . . . 260 

amphoric, 263 

cavernous, 263 



W. 

Walshe, on theory of consonance, . 
"Water-sound," . . . . 
Wavy respiration {vide Interrupted 

Respiration), 

Weak respiration (vide Diminished 

Vesicular Murmur), 
Whispering souffle, .... 
in dilatation of bronchia. 



260 
120 



214 



. 180 
. 260 
. 390 

in pneumonitis, .... 419 

in pulmonary tuberculosis, . 476, 480 

in tuberculous cdiviues (Appendix), 628 

Whispermg bronchophony {Appendix), 628 

Williams, explanation of tympanitic 

resonance over solidified lung, . 118 
Woillez, researches relative to devia- 
tions from symmetry, . . 21 
on effects of different diseases on 
the size of the chest, . . 316 



THE END. 



3477 
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